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diff --git a/27181-h/27181-h.htm b/27181-h/27181-h.htm new file mode 100644 index 0000000..53b81ee --- /dev/null +++ b/27181-h/27181-h.htm @@ -0,0 +1,3772 @@ +<!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Strict//EN" + "http://www.w3.org/TR/xhtml1/DTD/xhtml1-strict.dtd"> + +<html xmlns="http://www.w3.org/1999/xhtml"> + <head> + <meta http-equiv="Content-Type" content="text/html;charset=iso-8859-1" /> + <title> + The Project Gutenberg eBook of Prof. Koch's Method to Cure Tuberculosis Popularly Treated, by Max Birnbaum + </title> + + <style type="text/css"> + +/*<![CDATA[ XML blockout */ + +<!-- + + + p { margin-top: .75em; + text-align: justify; + margin-bottom: .75em; + line-height: 125%; + } + + h1,h2,h3,h4,h5,h6 { + text-align: center; /* all headings centered */ + clear: both; + } + + h1 { margin-top: 3em; + line-height: 125%; + } + + h2 { margin-top: 2em; + line-height: 125%; + } + + hr { width: 65%; + margin-top: 3em; + margin-bottom: 3em; + margin-left: auto; + margin-right: auto; + clear: both; + } + + table { margin-left: auto; + margin-right: auto; + } + + sup, sub { height: 0; + line-height: 1; + vertical-align: baseline; + position: relative; + } + + sup { bottom: 1ex; } + + sub { top: .5ex; } + + body { margin-left: 10%; + margin-right: 10%; + } + + p.mynote { background-color: #DDE; color: #000; + padding: 0.5em; + width:65%; + margin: 1.5em auto 0 auto; + font-family: sans-serif; + font-size: 85%; + line-height: 150%; + text-align:center; + } + + + .pagenum { /* uncomment the next line for invisible page numbers */ + /* visibility: hidden; */ + position: absolute; + left: 92%; + font-size: smaller; + text-align: right; + } + + .blockquot { margin-left: 5%; + margin-right: 10%; + } + + .center { text-align: center; } + .smcap { font-variant: small-caps; } + + .caption { font-weight: normal; + margin-top: 0.5em; + margin-bottom: 2em; + } + + .figcenter { margin: 2em auto 1em auto; + text-align: center; + } + + .footnotes { border: dashed 1px; } + .footnote { margin-left: 10%; margin-right: 10%; font-size: 0.9em; } + .footnote .label { position: absolute; right: 84%; text-align: right; } + .fnanchor { vertical-align: super; font-size: .8em; text-decoration: none; } + + // --> + /* XML end ]]>*/ + </style> + </head> + +<body> + + +<pre> + +The Project Gutenberg EBook of Prof. Koch's Method to Cure Tuberculosis +Popularly Treated, by Max Birnbaum + +This eBook is for the use of anyone anywhere at no cost and with +almost no restrictions whatsoever. You may copy it, give it away or +re-use it under the terms of the Project Gutenberg License included +with this eBook or online at www.gutenberg.org + + +Title: Prof. Koch's Method to Cure Tuberculosis Popularly Treated + +Author: Max Birnbaum + +Translator: Fr. Brendecke + +Release Date: November 7, 2008 [EBook #27181] + +Language: English + +Character set encoding: ISO-8859-1 + +*** START OF THIS PROJECT GUTENBERG EBOOK METHOD TO CURE TUBERCULOSIS *** + + + + +Produced by Bryan Ness, Norbert H. Langkau and the Online +Distributed Proofreading Team at https://www.pgdp.net (This +book was produced from scanned images of public domain +material from the Google Print project.) + + + + + + +</pre> + + + +<p class = "mynote">Inconsistent use of develops/developes, and centres/centers +has been retained as in the original.<br /><br /> +The printed book did not have a table of contents, +but has been added for this eBook. Page numbers in the "The first +communication" and "Explanatory Notes" have a 'c' prefix.</p> + +<h3>Table of contents</h3> +<table class = "toc" summary = "Table of contents" style="width:65%"> +<tr> + <td colspan="2" class = "number" style="text-align:right">Page</td> +</tr> +<tr> + <td><p>Translators Preface.</p></td> + <td class = "number" style="text-align:right"><a href = "#Page_1">1</a></td> +</tr> +<tr> + <td><p>Pulmonary Consumption.</p></td> + <td class = "number" style="text-align:right"><a href = "#Page_7">7</a></td> +</tr> +<tr> + <td><p>The other forms of Tuberculosis.</p></td> + <td class = "number" style="text-align:right"><a href = "#Page_29">29</a></td> +</tr> +<tr> + <td><p>The first communication</p></td> + <td class = "number" style="text-align:right"><a href = "#Page_c1">c1</a></td> +</tr> +<tr> + <td><p>Explanatory Notes.</p></td> + <td class = "number" style="text-align:right"><a href = "#Page_c19">c19</a></td> +</tr> +</table> + +<hr /> + +<div class="figcenter" style="width: 437px;"> +<img src="images/frontispiece_437.jpg" width="437" height="550" alt="Dr. Koch" /> +<div class="caption">DR. ROBERT KOCH.</div> +</div> + +<h1><span class="smcap">Prof.</span> KOCH'S<br /> +<i><span style="font-size:66%">METHOD TO CURE</span></i><br /> +TUBERCULOSIS<br /> +<i><span style="font-size:66%">POPULARLY TREATED</span></i></h1> + +<p class="center">BY<br />DR. MAX BIRNBAUM.</p> + +<p class="center" style="margin-top:3em;"><i>TRANSLATED FROM THE GERMAN</i><br />BY<br />DR. FR. BRENDECKE.</p> + +<p class="center" style="margin-top:3em;"><i>With an Appendix being Prof. Koch's First Communication + on the Subject, translated from the</i></p> + +<p class="center"><i>DEUTSCHE MEDICINISCHE WOCHENSCHRIFT</i></p> + +<p class="center" style="margin-top:1.5em;"><i>and explanatory notes by the author.</i></p> + +<p class="center" style="margin-top:4em;">MILWAUKEE, WIS.,<br />H. E. HAFERKORN,<br />PUBLISHER.<br />1891.</p> + +<p class="center" style="margin-top:3em;">COPYRIGHT 1890,<br />BY<br />H. E. HAFERKORN.</p> + +<p class="center" style="margin-top:3em;">PRESS OF THE<br />HARTMANN PRINTING CO.,<br />126 Reed St.,<br />MILWAUKEE, WIS.</p> + + +<hr /> +<p><span class='pagenum'><a name="Page_1" id="Page_1">[1–2]</a></span></p> + +<h2>Translators Preface.</h2> + + +<p>Consumption is curable. From time to time the news of +some great discovery rushes over the land like a mighty wave; +but never before has the intelligence of a great achievement +been received with such universal delight. There is hardly a +man, woman or child that does not bewail the loss of some +dear relative taken away by Tuberculosis, the most terrible of +all foes. More terrible because it stealthily creeps into the +system and takes a firm hold before its presence can even be +surmised.</p> + +<p>Now the appearance of a deliverer is hailed as would the +advent of the Messiah. Koch, formerly a poor and obscure +student, being especially interested in bacteriology has plodded +and worked for years. Even in the year 1882 he has made +known to the world the evil spirit in describing the tubercle-bacillus +as the specific generator of tuberculosis. We then +knew the enemy but had no weapon to fight him. Now Koch +has also manufactured the sword with which to combat the +evil genius. The experimental tests thus far have not tended +to lessen the merits of Koch's remedy. Added applications +have resulted in additional success. The investigations are +not yet complete; only meager particulars have thus far been +given to the public from authorized sources. To guard against +misleading representations the translator has undertaken to +give to the American public only what has actually been +achieved. He felt himself called upon to do this not only +because he has followed the progress of Koch's labors with +the keenest interest, but also because he himself has worked +and labored on this field for many years.</p> + + + +<hr style="width: 65%;" /> +<p><span class='pagenum'><a name="Page_3" id="Page_3">[3]</a></span>Justly has a vast excitement taken hold of all +classes of the people, an excitement that has +caused all other contemporary events to fall back. +The search for an actual remedy for that exceedingly +ravaging disease, tuberculosis, has at last been +crowned with success, and even the most uneducated +will be able to estimate the significance of this event.</p> + +<p>We need but consider, that pulmonary consumption, +the most frequent form of tuberculosis, annually +demands over 30,000 victims in the cities of the +German Empire over 15,000 inhabitants, and out +of every 100 deceased 12–13 have fallen prey to +this sickness.</p> + +<p>The number of sufferers from pulmonary consumption +can not nearly be determined, it certainly +exceeds all other diseases by far. In the case of +many people we can only infer from their appearance +and hereditary tendencies, before visible signs can be +discovered, that they will succumb to this terrible +disease.</p> + +<p><span class='pagenum'><a name="Page_4" id="Page_4">[4]</a></span>And this disease is now curable. Millions of +people who have considered themselves doomed, will +be given back to life; their regained strength will +greatly increase the national wealth. In short, we +look forward to an era, such as was not dreamt of +even by the most vivid imagination only a few years +back. But rather than be carried too far by our +enthusiasm, let us study Koch's new method to cure, +as far as we are now enabled to pass judgement +on it.</p> + +<p>First of all we must explain: <i>What is tuberculosis? +What relation does it bear to pulmonary +consumption?</i></p> + +<p>Pulmonary consumption is only one form of +tuberculosis, by far the most frequent. This is +the reason why pulmonary consumption, pulmonary +tuberculosis, consumption and tuberculosis are used +as <i>synonymous</i> terms.</p> + +<p>Tuberculosis is the <i>general</i> expression. By that +we understand a disease which is generated by a +certain kind of organism belonging to the class of +bacteria. These organisms are the tubercle bacilli, +which were discovered by Koch in the year 1882.</p> + +<p>Now these tubercle bacilli settle most frequently +in the lungs and here cause serious derangements +of the lung tissue. <i>Pulmonary consumption</i> is +the result.</p> + +<p><span class='pagenum'><a name="Page_5" id="Page_5">[5]</a></span>But the tubercle bacilli will also settle in any +other portions of the body and cause tuberculosis.</p> + +<p>Frequently the tubercle bacilli nestle in the +<i>larynx</i> and the result is <i>laryngeal consumption</i>.</p> + +<p>They may infect the mucous lining of the tongue +and nasal passages and cause the rarely occurring +diseases—<i>tuberculosis of the tongue and nose</i>.</p> + +<p>More frequently tuberculosis of the intestines +results, the well-known <i>intestinal consumption</i>.</p> + +<p>The spreading of tuberculosis in the brain is of +especial importance on account of the importance of +this organ. Very frequently small children are +attacked by <i>tuberculosis</i> of the <i>cerebral membranes</i>, +a disease that has heretofore unexceptionally resulted +in <i>death</i>.</p> + +<p>Much oftener than is generally supposed the +<i>kidneys</i> are the seat of tuberculosis; and also the +<i>suprarenal capsules</i>, whose functions are as yet +entirely unknown, have in postmortem examinations +been found to be tubercularly degenerated.</p> + +<p>In the diseases of the <i>bones</i> and <i>joints</i> tuberculosis +forms an important part. Those infinitely small +and weak tubercle-bacilli have the power to destroy +the hard and firm substance of the bones, to soften +it and change it to pus. Whole portions of bone may +disappear in this way.</p> + +<p><span class='pagenum'><a name="Page_6" id="Page_6">[6]</a></span>Tuberculosis can also destroy parts of the <i>skin</i>. +In this case it is called <i>Lupus</i>.</p> + +<p>Finally tuberculosis is found in the <i>generative +organs</i>. Tubercular derangements are frequently +met with in the <i>testicles</i> of men, less often in the +<i>ovaries</i> of women.</p> + +<p>The well known children's disease <i>Scrofula</i> is +considered a preceding stage of tuberculosis by many +physicians. This much is certain that Scrofula +inclines to tuberculosis.</p> + +<p>Let us study the several forms of tuberculosis +after this general synopsis; we will begin with pulmonary +consumption.</p> + + +<p><span class='pagenum'><a name="Page_7" id="Page_7">[7]</a></span></p> +<h2><a name="Pulmonary_Consumption" id="Pulmonary_Consumption"></a>Pulmonary Consumption.</h2> + +<p>Even before the discovery of the tubercle-bacillus +by Koch, different scientists had claimed that +pulmonary consumption was caused by the immigration +of bacteria into the lungs, and several of them +had found bacteria of that kind. But it remained +for Koch to bring light upon the conjectures of other +scientists, and he established the fact, that the +bacillus discovered by him was the real generator of +pulmonary consumption. Millions of these bacilli +exist in the lungs of the diseased, and millions of +them are thrown out with the sputum.</p> + +<p>If we take a very small quantity of this thrown +out matter and examine it with a microscope, we +will find a greater or smaller number of these +tubercle bacilli. Of course the preparation to be +microscopically examined must previously be colored +with some coloring matter, otherwise it is very +difficult, well nigh impossible, to detect the infinitely +small bacilli. The method of coloring now generally +in use consists in discoloring the preparation after +the coloring has been completed, it is found that the +bacilli tenaciously cling to the coloring matter, and +in this way it is easy to recognize the tubercle-bacilli +under the microscope.</p> + +<p><span class='pagenum'><a name="Page_8" id="Page_8">[8]</a></span>These bacilli are infinitely minute, they are <small><sup>2</sup></small>⁄<small><sub>1000</sub></small> +to <small><sup>8</sup></small>⁄<small><sub>1000</sub></small> millimeters long, and about <small><sup>5</sup></small>⁄<small><sub>100000</sub></small> millimeters +in width. Therefore it is absolutely impossible to +recognize them with the naked eye. Generally they +are somewhat bent, sometimes slightly nicked at one +end.</p> + +<p>The temperature of boiling water destroys the +vitality of the bacilli under all circumstances. Even a +temperature of 70° C. is able to lessen the efficacy of +the bacilli. Unhappily this temperature is too high +to be applied against the tubercle-bacilli in the +human body without causing the most serious injury +to it. Nevertheless it has been tried, we will speak of +this later on.</p> + +<p>Then the drugs that kill the bacteria, such as +Carbolic Acid, Alcohol, Iodoformether, Ether, Sublimate, +Thymol, destroy the tubercle-bacilli so slowly +and only in such high concentrations that their +application is impossible without endangering the +patient. Therefore the prospects of directly destroying +the bacilli in the human body had to be given up +as impossible.</p> + +<p>We are now confronted with two questions:</p> + +<div class="blockquot"><p>1. In what manner does the tubercle-bacillus enter into the human +organism?</p> + +<p>2. Under what conditions is the tubercle-bacillus able to generate +pulmonary consumption after it has entered the human organism?</p></div> + +<p><span class='pagenum'><a name="Page_9" id="Page_9">[9]</a></span>All investigations, both of earlier and later date +have established the fact that the tubercle-bacillus +is inhaled with the air, and then it is mainly the foul +air which is accused. But foul air is especially found +in such places where people congregate, as in rooms, +barracks, factories, etc. As it is a fact that there are +always several consumptives among a number of +people, so in this case there will always be occasion +to inhale the tubercle-bacilli that have been cast out +by the consumptives. Therefore it is not the foul air +in itself which generates pulmonary consumption, +but the circumstance that in this connection there +are always people present which are able to spread +and scatter the bacilli.</p> + +<p>Luckily the physical qualities of the tubercle-bacilli +are such that they mostly adhere to the +ground or floor and are rarely scattered in the air as +dust; otherwise pulmonary consumption would be +much more frequent than it is at present. Unfortunately +the bacilli are very often spread through +uncleanliness of the people, because they touch objects +with their fingers to which the tubercle-bacilli +chance to stick and then they touch their mouth or +nose with these fingers. In this way bacilli can be +taken into the system especially easily with the food. +Children are particularly exposed to contamination, +crawling about on the ground, on which, perhaps +but recently, a consumptive has spit, and more so<span class='pagenum'><a name="Page_10" id="Page_10">[10]</a></span> +because they often have the habit to put all sorts of +things and also the generally dirty fingers into +their mouth.</p> + +<p>On the other hand there are various obstacles in +the way of tubercle-bacilli entering the lungs. The +distance from the mouth to the lungs is long and +narrow; all sorts of projections check the further +penetration of the bacilli. The trachea and the air-passages +of the lungs possess equipments arranged +for the purpose of ejecting small foreign substances, +thus also to throw out the bacilli. In short it is not +too easy a matter for the bacilli to penetrate into +the lungs.</p> + +<p>And yet this happens only too often. For +instance, in some people the passage from the mouth +down may be a wide one, so that the bacilli can +enter more easily; the protective arrangement by +which foreign substances are removed may be deranged, +it may be wanting in some place or its +functionary qualifications may be bad; especially +frequent this is the case after enfeebling diseases, +which are associated with severe cough, as measles, +whooping-cough, etc. This is the reason why pulmonary +consumption is strikingly often observed to +follow just these diseases.</p> + +<p>But the tubercle-bacillus can also enter the body +with the food, as stated before. The acid gastric +juice is a protective agent which considerably lessens +the danger of infection by tuberculosis.</p> + +<p><span class='pagenum'><a name="Page_11" id="Page_11">[11]</a></span>It has not been definitely decided at the present +time whether the drinking of milk from tuberculous +cows brings with it the danger of tuberculosis for +mankind. It will certainly be best to avoid such +milk, especially when the cow's udder is found to be +tuberculously diseased or when tubercle-bacilli can be +traced in the milk.</p> + +<p>The use of meat as food may also become +dangerous to man, but this is a rare occurrence. It +is particularly dangerous to eat the liver, kidneys +and lymphatic glands of tuberculous animals. The +boiling heat while cooking generally destroys the +bacilli contained therein and so lessens the danger +from this source. It is of no little importance, to +call particular attention to the fact that our chickens +are very often severely infected with tuberculosis.</p> + +<p>The question, whether a consumptive can <i>infect +his surroundings</i>, may be answered thus, that this +does <i>not</i> happen as a rule. Several unhappy circumstances +must come together to make this possible. +Above all things a direct transmission of tubercle-bacilli +in some way into the body of the healthy +person, then the bacilli must cling and propagate in +the same, which is only possible when there is an inclination +to this disease, of course this inclination is +quite common.</p> + +<p>Pulmonary consumption is <i>not hereditary</i> in the +strict sense of the word. Only an inclination to this<span class='pagenum'><a name="Page_12" id="Page_12">[12]</a></span> +disease is transmitted. As the danger of contagion +of those having such disposition is very great, so as +a rule the disease makes its appearance sooner or +later.</p> + +<p>On the other hand it must be considered that the +penetration <i>only</i> of the tubercle-bacilli into the +body is <i>not</i> sufficient to generate tuberculosis. If +they do not find the ground adapted to their nourishment +and propagation they perish. It may be +assumed that every person is placed in such circumstances +at some time that he will take in tubercle-bacilli; +but only a certain percentage will get consumption. +In the remainder the bacilli perish +without leaving even a trace.</p> + +<p>Very often the inclination to pulmonary consumption +may be recognized from the external +characteristics. As a rule the respective individuals +have a slight body, thin lean skin, weak muscles, +delicate skeleton, a long, narrow, flat chest, flattening +of the regions over and below the shoulderblades, +wide intercostal spaces, a winglike projecting of the +scapulæ, long neck, clubby, knoblike appearance of +the ends of the fingers.</p> + +<p>Furthermore it has been found, that pulmonary +consumptives on an average have a <i>smaller heart</i> +than is essential to a healthy body. On the other +hand the volume of the lungs of consumptives is very +often abnormally large.</p> + +<p><span class='pagenum'><a name="Page_13" id="Page_13">[13]</a></span>There are a large number of <i>diseases</i> that predispose +to pulmonary consumption. It is mainly the +<i>enfeebling</i> action of the same, which brings about +such results. For this reason the <i>chronic</i> diseases +contribute so much toward the multiplication of the +number of consumptives, because they stipulate a +continuous weakening of the organism and an emaciation +of the system. To these belong Bright's +disease, which very often turns into pulmonary consumption, +greensickness or chlorosis, anaemia, continued +febrile diseases, severe chronic suppuration, +chronic catarrh of the stomach, frequent pregnancies, +childbed diseases. Thus we may often see young +chlorotic girls afflicted with consumption, especially +when they marry young and enjoy the honeymoon +to its utmost limits. Then also women will easily +become consumptive when they give birth to a child +every year, especially when the social conditions in +which they live are of an unfavorable nature, and +they are perhaps inclined to consumption already. +Childbed on the whole inclines to arousing the +dormant inclination toward pulmonary consumption.</p> + +<p>Of other diseases we have mentioned measles and +whooping cough, as diseases that are only too easily +succeeded by consumption. To these may be added +typhus, especially when it is of a more protracted +nature, and the reconvalescence is slow and incomplete.</p> + +<p><span class='pagenum'><a name="Page_14" id="Page_14">[14]</a></span>Furthermore all those workmen that have to do +with dust, are exposed to the danger of being stricken +with pulmonary consumption. The dust enters the +lungs, irritates and injures the same and so produces +a favorable soil for any tubercle bacilli that may +happen to penetrate. On the whole metal dust is +more injurious than mineral dust. Workmen, that +are exposed to animal dust, as furriers, saddlers, +brushmakers, fall prey to consumption much oftener +than those, that fulfill their vocation in air pregnant +with vegetable dust. According to statistics workingmen +are stricken with pulmonary consumption as +follows: of glass workers 80 per cent., needle grinders +70, filemakers 62, stone cutters 40, mill grinders, +lithographers, cigarmakers, brushmakers, stone-polishers +40–50, millers 10, coal workers 1 per cent.</p> + +<p>Pneumonia may culminate in pulmonary consumption: +but on the whole this rarely happens. +Much oftener it is the case with Pleurisy. But it is +assumed and rightly, that most people who are +attacked by pleurisy, are already consumptive.</p> + +<p>A hemorrhage of the lungs may nearly always be +considered a sure sign that consumption has taken +hold of the respective individual; but such a hemorrhage +certainly forms considerable danger to falling +a victim to tuberculosis, if the individual is as yet +free from the same.</p> + +<p><span class='pagenum'><a name="Page_15" id="Page_15">[15]</a></span>Age has a particularly decided influence on the +origin of consumption; it is extremely rare before +the third or fourth year, from that to the seventh it +is more frequent; it most frequently occurs in the +age from the fifteenth to the thirtieth year, and from +there on the chances are again fewer. In very old +age it is again very rare.</p> + +<p>There seems to be no essential difference as +regards sex.</p> + +<p><i>Insufficient</i> or <i>defective nourishment</i> acts as a +promoter in various ways. Even the nourishing of +infants with poor milk, with bread or flour-pap +increases the disposition to pulmonary consumption. +If this defective nourishment is continued, scrofula +will surely follow and this is a stage antecedent to +consumption.</p> + +<p>Pulmonary consumption is relatively more +frequent among the <i>poorer</i> than the <i>well to do +people</i>, this is partly due to the meagre and scanty +food of the poorer, and that they are obliged to +subsist almost exclusively on vegetable diet. The +higher the meat prices rise and the less the majority +of the people can afford to procure meat, the larger +will be the number of consumptives. The poorly +nourished offer a good soil for the tubercle bacilli +in consequence of their weakness. The tissue offers +little or no resistance to the growth of the bacilli, +these propagate and destroy the powerless and +yielding organism with fearful rapidity.</p> + +<p><span class='pagenum'><a name="Page_16" id="Page_16">[16]</a></span>The <i>frequency</i> of pulmonary consumption increases +with the <i>size of the cities</i>, or, which is the +same, with the number of proletarians. Extreme +hunger and want are less frequent in the country +than in the city.</p> + +<p>That the climate has an important influence on +the appearance of pulmonary consumption has long +been known. In certain elevated regions this disease +seldom or never appears. This experience has been +attained in Switzerland and many other mountain +regions. Furthermore the Plateaux of Peru and +Mexico are considered free from consumption, but +also lowlands like Iceland, the Kirgheez steppes and +the interior of Egypt are known to be exempt.</p> + +<p><i>Damp and windy climate</i>, especially with very +high temperature, or abrupt changes in the temperature +promotes consumption; on the other hand it +is less frequent in the more moderated climates, +especially if they are dry.</p> + +<p>Now when the tubercle bacilli have settled in the +lungs, they cause various symptoms. One of the +most frequent is <i>cough</i>. In the beginning of the disease +a short, clear but light, very often dry cough appears. +During the further development of pulmonary +consumption the cough becomes more periodic; it +appears early after awaking, in the afternoon after +dinner, and evenings at lying down; it may disappear +entirely in the meantime or may be light only; +but then as a rule it is no longer dry, but may be +attended by expectorations of a varied nature.</p> + +<p><span class='pagenum'><a name="Page_17" id="Page_17">[17]</a></span></p> +<div class="figcenter" style="width: 550px;"> +<img src="images/f01_550.png" width="550" height="545" alt="Tuberculous knot in the lungs" /> +<div class="caption">Section of a tuberculous knot in the lungs, in which two cavities are seen +filled with numerous bacilli. The bacilli distinctly appear as dark lines as a +result of the coloring. Enlargement 900.</div> +</div> + +<div class="figcenter" style="width: 550px;"> +<img src="images/f02_550.png" width="550" height="216" alt="Tubercle bacilli" /> +<div class="caption">Tubercle bacilli, Enlargement 2000.<br /> +To the left bacilli without spores, to the right bacilli with colorless sections +which are thought to be spores.</div> +</div> + +<p><span class='pagenum'><a name="Page_18" id="Page_18">[18]</a></span>The tubercle bacilli destroy the lung tissue and +change it into pus, which is coughed out. In this +way larger and smaller cavities are formed in the +lungs; finally the cavities may even take more space +than the remaining lung tissue. When cavities have +already been formed, coughing comes easy and with +abundant expectoration. Toward the end of life the +coughing and spitting stops as a result of the extreme +feebleness and weakness.</p> + +<p>The violence and frequency of the cough depends +mainly whether the larger bronchial tubes and the +trachea are affected; the more this is the case, the +more violent the inclination to cough. Further the +strength of the cough depends on the excitability of +the patient; the greater this is, the more as a rule +will he cough. Sometimes the position of the +patient is of influence; if he lies mostly on the +diseased side the expectoration becomes more difficult +and coughing increases.</p> + +<p>Coughing is generally that symptom which +soonest attracts the attention of the patient and his +surroundings. For that very reason consumption +is in its beginning stages easily confounded with +such other diseases as are also accompanied by +cough.</p> + +<p><span class='pagenum'><a name="Page_19" id="Page_19">[19]</a></span>At the same time we know of exceptional cases +where cough was entirely absent in the first stages +of the disease, or was at least so slight that it was +overlooked, and under such conditions the pale and +poor appearance and reduced strength is mistaken +for chlorosis or some other anaemic affection, also +the existing febrile excitements are wrongly judged, +or on account of lack of appetite or light derangements +of the stomach a stomachic affection is +surmised, until suddenly a hemorrhage of the lungs +clearly defines the true nature of the ailment.</p> + +<p>On the other hand the cough may become so +violent that vomiting is caused at the same time. +Nevertheless many consumptives describe their cough +as very unimportant on account of their innate +sorrowless nature, and they will not even be discouraged +by the gravest symptoms. Often however it is +fear that induces the patients to make light of their +coughing, their spitting blood, their losing flesh and +to place but little importance on these circumstances. +A <i>hoarse</i> cough is a sure sign of a diseased <i>larynx</i>.</p> + +<p>Many consumptives complain of cutting pains +between the shoulderblades, under the clavicles or in +the side; but these are rarely intense and are often +entirely wanting. Unfortunately it is unknown to the +average layman that the internal organs may suffer +extensive tearing down without an indication of +pain.</p> + +<p><span class='pagenum'><a name="Page_20" id="Page_20">[20]</a></span>The <i>Expectoration</i> of consumptives which is +thrown out by coughing with great exertion, is but +scant in the beginning, as a rule phlegmy, glassy +transparent and sticky. It is one of the suspicious +symptoms of developing pulmonary consumption if +this lasts for any greater length of time. Sometimes +sharply defined, yellowish stripes, at times branching, +appear in the same. Later on the expectoration +becomes more purulent, and of greenish-yellow or +greenish-gray color.</p> + +<p>Still later the patients throw out rounded lumps +of greenish yellow or yellowish green color, which +flatten out like a coin in the spittoon. They sink in +water which is a sign of forboding evil.</p> + +<p><i>Blood</i> appears in different quantities in the +sputum of consumptives. Bloody streaks are of no +importance; they may appear with every violent +cough. On the other hand the casting out of <i>pure +blood</i> is indeed serious.</p> + +<p>The <i>quantity</i> of blood thrown out during an attack +may be very different, varying from a few drops +hardly a teaspoonful, to hundreds of grammes, even +more than a liter. It is generally light red, filled +with airbubbles, foamy, and is largely coughed out +in coagulated lumps. The coughing of blood is sometimes +preceded by a feeling of oppression, rushing +of blood to the head and palpitation. Some patients +experience a sweet taste in the mouth even before the<span class='pagenum'><a name="Page_21" id="Page_21">[21]</a></span> +bleeding. In many cases all preceding symptoms +are missing and the patient is suddenly attacked by +blood coughing during some more vigorous movement, +during the exertion of coughing or even without +any direct cause.</p> + +<p><i>Blood coughing</i> seems to appear somewhat +more frequently with the <i>female</i> sex than with the +male and has with them unmistakable relations to +menstruation, as with the sick it often sets in before, +often after or even during the same and at such +times more frequently than at others.</p> + +<p>It is of great importance for the layman to know +that a hemorrhage rarely leads to inevitable death. +Fatal hemorrhages are always preceded by warning +attacks. Blood coughing may appear at any stage +of consumption. In some cases it is particularly +lasting. Sometimes the patients experience considerable +relief from their feeling of oppression after a +hemorrhage.</p> + +<p>A number of the consumptives as a rule complain +of <i>difficulty</i> in <i>deglutition</i>. This is caused by ulcers +on the posterior wall of the larynx.</p> + +<p>With many patients the <i>appetite</i> is <i>undisturbed</i> +for a long time, and there are consumptives that will +eat a comparatively large dinner during an attack +of fever reaching 40° C. Generally the desire to eat +disappears during the course of the disease, especially +toward the end of the sickness.</p> + +<p><span class='pagenum'><a name="Page_22" id="Page_22">[22]</a></span>The <i>stool</i> may be normal or costive, but is very +often diarrhoetic. Twelve or more evacuations may +take place during a day; as a rule they are much +increased by gasses and are of bad odor. They +weaken the patient very much and hasten the end.</p> + +<p>One of the most constant attendants during the +course of consumption is the <i>Fever</i>. It is rather +irregular. In cases of slow process the fever is often +very insignificant; often it is only a state of general +excitement that takes hold of the patient afternoons, +slight dizziness, increased lustre of the eyes, slightly +flushed appearance, somewhat increased pulse, which +invites to test the temperature of the body by means +of a thermometer, which by the way shows it to be +about 38° C. With quick consumption the fever is +generally high.</p> + +<p><i>Sweat</i> is also a characteristic sign. The exceedingly +debilitating effect of night-sweats is well +known.</p> + +<p>During the course of pulmonary consumption +extreme <i>emaciation</i> of the patient is brought about. +All tissues are subject to the same, most marked is +the disappearance of adipose tissue. This symptom is +of the greatest importance as a continued increase in +weight means improvement and even cure. Therefore +weighing the patient from time to time gives a sure +meter for the course of the disease.</p> + +<p><span class='pagenum'><a name="Page_23" id="Page_23">[23]</a></span>The <i>course</i> of pulmonary consumption is very +different. With quick consumption the end comes +within two or three months. Chronic pulmonary +consumption may last for years. With this improvements +in the fine season alternate with deterioration +in the winter.</p> + +<p>Concerning the former <i>treatment</i> of pulmonary +consumption, this will also be applied in the future in +the same manner as far as preventive means and +general hygiene is referred to.</p> + +<p>For every one will prefer to remain exempt from +consumption although it may now be possible to +cure those afflicted. The lately published and popularly +treated precautionary measures, especially with +reference to the expectoration of consumptives retain +their full value.</p> + +<p>Henceforth the sputum is also to be thrown in +a <i>spittoon</i> which is either entirely empty or on +account of easier cleansing has the bottom covered +with a thin layer of water. It should not be permitted +to fill the spittoons with sand or sawdust as +the tubercle bacilli can be easily thrown up with the +dust.</p> + +<p>In the case of a <i>sudden attack</i> of <i>cough</i> a <i>cloth</i> +should be held to the mouth to hinder spreading of +the fine spray, the same should also be used for +wiping the mouth. However the cloth must soon be +dampened and cleaned.</p> + +<p><span class='pagenum'><a name="Page_24" id="Page_24">[24]</a></span>As bits of the sputum easily stick to the <i>beard</i> +especially the moustache overhanging the lips, +therefore lung consumptives are advised to wear a +short or no beard.</p> + +<p><i>Glasses</i>, <i>spoons</i>, etc. used by consumptives must +only be used by other persons after a thorough +cleaning with hot water.</p> + +<p>The lungdiseased person should abstain from all +active and passive <i>kissing</i>, in unavoidable cases +kissing should be done on the forehead or cheek only, +or hold out those parts only to be kissed. In the same +way he should avoid to touch objects with his mouth +that may possible be put in the mouth by other +persons, especially children, for instance toy-trumpets.</p> + +<p>In the case of <i>death</i> from pulmonary consumption, +the walls of all rooms and apartments used by +the deceased should be rubbed down with fresh baked +bread, which is a sure method of removing the bacilli. +The bread crumbs that may have dropped on the +floor may be removed by a thorough scrubbing with +soap, brush and lye.</p> + +<p>Upholstered furniture, beds, clothes and wash +should be cleaned in a disinfecting place.</p> + +<p>Do not wait with precautionary measures till +some member of the family has been attacked by +pulmonary consumption, but make preparation to +prevent the infection while everybody is still sound +and healthy.</p> + +<p><span class='pagenum'><a name="Page_25" id="Page_25">[25]</a></span>This care ought to begin in a measure with the +<i>birth of a child</i>. The same should not be nursed by +a mother with diseased lungs nor by a wet-nurse +with like affections. Generally wet-nurses are only +tested for syphilis; scrofula and tuberculosis receive +altogether too little attention.</p> + +<p>An important precautionary measure consists in +the supervision of the <i>food</i>. The abattoirs and +dairies should be placed under the supervision of +practical physicians, and the sale of products derived +from tuberculous cattle be prohibited. This refers +to the milk in the first instance. Tuberculous cows +should be excluded from dairy-farms. Raw milk +should be avoided as much as possible as boiled milk +has the same value.</p> + +<p>The <i>meat inspection</i> must be strictly conducted +especially with reference to tuberculosis in the case +of beef, pork and chickens. Sheep are not subject to +tuberculosis.</p> + +<p>The <i>associations</i> of children in school and on the +play-ground should be watched; do not let them +visit in strange families before making thorough investigation +as to their sanitary relations.</p> + +<p>The health of <i>servant girls</i> should receive greater +attention than formerly, as the disease is often +carried into the house by them as investigation has +proven.</p> + +<p><span class='pagenum'><a name="Page_26" id="Page_26">[26]</a></span>In the <i>schools</i> and kindergartens the teacher +ought to insist that children do not spit on the floor +or in the handkerchief; in case of necessity he should +keep sick children out of school and he should especially +follow these precautionary measures as +regards his own person.</p> + +<p>The <i>cleaning of the floor</i> of a room should always +be done in a damp way.</p> + +<p><i>Moving</i> into another house it is advised to rub +down the walls with fresh baked bread.</p> + +<p>As regards <i>societies</i>, every society and every +health resort without exception and if possible every +hospital should be obliged to have its own apparatus +for disinfection and to make extensive use of it. +Smaller societies may unite to procure an apparatus +of the kind.</p> + +<p>Especial attention should be given to the <i>sprinkling +of the streets</i> during the dry season.</p> + +<p>The state and the larger congregations should +make it a point to maintain <i>institutions for consumptives</i>, +beyond the city limits if possible, a +healthy location in the country preferred.</p> + +<p>Every one individually protects himself best from +consumption by a methodic habit of <i>washing with +cold water</i>, cold rubbing and baths. River and sea +baths are generally of excellent results; short shower +baths with cool water lasting 20–40 seconds are to<span class='pagenum'><a name="Page_27" id="Page_27">[27]</a></span> +be applied later on; they do not only harden the skin +but excite deep inhalations and exhalations and in +that way act as gymnastics of the lungs. More direct +is the action of muscular exercise, such as gymnastics, +riding horseback or bicycle, driving, skating, rowing, +etc. The carriage of children must be regulated, the +drooping forward of their shoulders must be corrected +by strengthening the muscles of the back and +shoulders by means of dumbbell and other exercises.</p> + +<p>All this must still be observed in the future. On +the other hand above all the numberless remedies +will be dropped that have heretofore been applied as +presumably specific remedies for consumption.</p> + +<p>Creosote, which was so much praised at its appearance +a few years ago and still applied, because +of the non-existence of a better remedy, will be +dropped into obliteration and with it Guajacol which +was just getting to be the "fashion".</p> + +<p>All the various inhalation methods that have +matured in later years will disappear from the +picture plane as far as this has not ever now happened.</p> + +<p>The medical remedies, which were given for the +torturing cough, for hemorrhage of the lungs, sweats +etc., will in most cases be superfluous after this. +Hemorrhages will now and then still be experienced +as the same may set in unexpectedly.</p> + +<p><span class='pagenum'><a name="Page_28" id="Page_28">[28]</a></span>The diatetic cures with whey, koumiss, grapes etc. +will retain their importance and also the bathing resorts +will be hunted up by patients as formerly.</p> + +<p>The owners also of special institutes for curing +pulmonary consumption need not despair with the +idea that they will not be needed in the future. On the +contrary, those needing cure will flock to them in all +the greater numbers, as they now know that they +certainly will be restored to health within a definitely +limited time.</p> + + +<p><span class='pagenum'><a name="Page_29" id="Page_29">[29]</a></span></p> +<h2><a name="The_other_forms_of_Tuberculosis" id="The_other_forms_of_Tuberculosis"></a>The other forms of Tuberculosis.</h2> + + +<p>Of the other forms of tuberculosis <i>laryngeal consumption</i> +is very often combined with pulmonary +consumption. It is estimated that this is true of at +least one-fourth of all cases of pulmonary consumption.</p> + +<p>At first laryngeal consumption can not in any +way be distinguished from an ordinary inflammation +of the larynx. A certain weakness and sensitiveness +of the organs however is suspicious, also great +liability to hoarseness. On the other hand laryngeal +consumption may exist without any sort of ailing to +the patient.</p> + +<p>These appear later, however, when lung tuberculosis +is progressing. The larynx shows more distinct +outlines on the lean throat, difficulty in swallowing +is experienced, pains radiate toward the ear. Food +and drinks come up again after being swallowed.</p> + +<p>The painful cough has a hollow, barking, harsh +sound, provokes vomiting, and the sputum together<span class='pagenum'><a name="Page_30" id="Page_30">[30]</a></span> +with foul breath consists of foamy, slimy, purulent +lumps. Breathing gradually becomes more difficult +and louder.</p> + +<p>As regards the duration of laryngeal consumption +it generally runs parallel with pulmonary consumption. +If the latter progresses more rapidly +so also will the destruction of the larynx by the +tubercle-bacilli be a more rapid one and vice versa. +In several cases it has been observed that, if pulmonary +consumption progressed or remained without any +extraordinary symptoms, those with diseased larynx +have lived for years, with alternating improvements +and diminutions, and also an occasional suspension +of all symptoms, till on account of often only a trivial, +evil influence a new stimulus is given and the disease +found an unexpectedly rapid completion of its course.</p> + +<p>Until now only few cases of laryngeal consumption +could be looked upon as really cured. Lately it +has been tried to accomplish cures especially by the +application of caustics. This will not now be necessary. +But those afflicted in this way, will henceforth +be obliged to try and live in air free from dust, to +travel south during the winter and to subject themselves +to a general strengthening treatment.</p> + +<p><i>Tuberculosis</i> of the <i>tongue</i> is relatively very +scarce. The individual in such a case nearly always +shows pronounced pulmonary tuberculosis. Sometimes<span class='pagenum'><a name="Page_31" id="Page_31">[31]</a></span> +tuberculosis of the tongue is combined with +tuberculous sores on the lips and also on the anus.</p> + +<p>Tongue tuberculosis forms small ulcers, generally +on the rim, very seldomly on the back of the tongue. +They always are very small, generally about the +size of lentils or peas. They often remain unchanged +for months. At times they are very painful, though +as a rule the pain is mild. The male sex is attacked +by tongue tuberculosis especially frequently.</p> + +<p>The treatment before this consisted in cutting +out all the diseased parts; now it will be much +simpler.</p> + +<p><i>Nasal tuberculosis</i> appears similar to the common +stopping up of the nose. But when ulcers are +formed, the secretions from the nose take on a +purulent somewhat malodorous character. But if +the affection is neglected, the secretion becomes +bloody and of very bad odor.</p> + +<p>Until now nasal tuberculosis had been treated +by applying caustics to the ulcerated portions.</p> + +<p><i>Tuberculosis of the intestines</i> or <i>intestinal consumption</i> +is especially found in <i>children</i>. The +appearance of the same is already characteristic; +the limbs are emaciated and withered; the old-looking +wrinkled face shows a harsh contrast with +the immoderately expanded body (frog-belly) which<span class='pagenum'><a name="Page_32" id="Page_32">[32]</a></span> +is caused by an accumulation of gases in the limp +intestines which are then filled to bursting. Many +such children have succumbed to gradually progressing +emaciation and weakness.</p> + +<p>Probably it will not be possible to save all +children in the future that have been stricken with +this disease as many are wanting in sufficient vitality +to resist all external influences.</p> + +<p>With adults intestinal consumption makes itself +known by everlasting diarrhoea, a result of the +numerous ulcers in the intestines which have been +caused by the tubercle-bacilli.</p> + +<p><i>Tuberculosis of the brain and of the cerebral +membranes</i> also attack children especially. Before +this no attempts have been made to try whether it is +now possible to cure the <i>tuberculous inflammation of +the cerebral membranes</i> which has previously been +unconditionally fatal. The decision will certainly +soon be made.</p> + +<p>We will give a fuller description of the symptoms +of this disease to thus enable timely summons of +medical interference. This disease will be known to +many as "acute hydrocephalus."</p> + +<p>As a rule children of 2–7 years of age are attacked +by this fearful disease. The antecedents are +extremely peculiar and manifold. Even two or three +weeks before the outbreak of the real sickness, emaciation<span class='pagenum'><a name="Page_33" id="Page_33">[33]</a></span> +takes place from which the face is strangely +enough entirely exempt, so that children, when +dressed show no signs of a change. Attentive +mothers and nurses, however, regularly notice the +same and especially the appearance of the ribs +causes no little anxiety. With this a slight pallor of +the face is associated and a peculiar lustre of the +eyes. The children lose their former feeling of +gayety and activity. They sleep more than usual, +withdraw from their favorite game, they become +grumbly and shy toward their surroundings +and cry for the slightest reason. It also is very +peculiar that they avoid trying their former little +tricks, such as climbing up on chairs, opening of +door bolts that are almost out of their reach, they +even will not try to look through a latticed window +and asked to do so, decidedly refuse. Boys, that +would not stand anything from their associates, +that fought and wrestled as long as their strength +permitted it, sneak away cowardly and crying from +such attacks. Other children again become extraordinarily +tender-hearted and affectionate, they hug +their parents continually and can hardly console +themselves when they leave them.</p> + +<p>In the case of older children that have already +learnt something, teachers notice unusual inattention +and indifference, committing to memory comes +harder than usual and what is finally learnt is +recited in an awkward and stammering way. The<span class='pagenum'><a name="Page_34" id="Page_34">[34]</a></span> +children sleep unusually much and often by day; on +the other hand their sleep at night is less sound and +is interrupted by horrid dreams, frequent turning +over in the bed and frequent clamorous outcries.</p> + +<p>The appetite is lessened, and often a craving is +noticed for stimulating food of which, however, little +is eaten. Thirst is not increased. Urinal secretion +is somewhat diminished and the urine is characterized +by a brick-colored precipitate. The stool is +rather costive, especially with larger children; but +diarrhoea may attend this disease. The latter is +principally the case with small children that are in +the stage of first teething.</p> + +<p>Headache is rarely felt and hardly ever complained +of even by larger children; dizziness and +unsteady walking is frequently observed. The +children quite often complain of stomach-ache, which +is very much increased by pressure on the abdomen.</p> + +<p>Fever is not generally attendant, but the same +may be present.</p> + +<p>The symptoms just described, separately or +collectively, gradually increase; the children finally +take to their bed and now the <i>real cerebral affection</i> +developes.</p> + +<p>Now the principal symptoms are: vomiting, constipation, +slow pulse, irregular abrupt breathing, +increased temperature of the skin, contracted abdomen,<span class='pagenum'><a name="Page_35" id="Page_35">[35]</a></span> +headache, great excitement alternating with +drowsiness, beginning decrease of reason, and deranged +ability of moving the limbs.</p> + +<p>As regards <i>vomiting</i>, this is almost a continuous +symptom and generally appears in the earlier stages. +But the duration of vomiting is very different. +Some children vomit only for one or more days and +not all they have eaten, while others vomit continuously +from the beginning of the disease till they are +relieved by death, and no food can be found that is +not thrown up shortly after its being eaten. In this +connection it is a peculiar fact that vomiting will +not recur if it has once ceased for twenty-four hours.</p> + +<p>Very important for the recognition of the disease +is the manner of vomiting. For a child suffering +from a spoiled stomach will be troubled with nausea, +belching, choking and cold sweat long before it is +forced to vomit, while children with acute hydrocephalus +will throw up without any previous symptoms +of that kind, just as though they filled the +mouth with water and spit it out again. Vomiting +is facilitated when children are raised or placed on +their side. It ceases for the time the stomach is +empty, but as soon as fluid or even solid food is +taken in it will be cast out at once without +causing any particular distress or inconvenience to +the child. Gall is very rarely mixed with the vomit.</p> + +<p><span class='pagenum'><a name="Page_36" id="Page_36">[36]</a></span>A second and nearly as constant a symptom is +<i>constipation</i> from which nearly three-fourths of the +diseased children suffer. As a rule cathartics have +no effect and are generally thrown out through the +mouth. This constipation will not last till the end, +for a few pappy stools appear later on whether +purgatives are administered or not. Violent diarrhoea +resulting from intestinal tuberculosis may be +discontinued at the beginning of acute hydrocephalus. +But the later stools will again be thin and of +cadaverous odor.</p> + +<p>During the latter stages of the disease children +will often <i>fail to pass urine</i> for twenty-four hours, so +that the physician is obliged to draw it off with a +catheter.</p> + +<p>The appetite does not disappear entirely as a +rule. There may not be any desire for food, but +generally little difficulty is experienced in inducing +children to take milk or broth, which is all the more +surprising as vomiting regularly follows.</p> + +<p>The <i>fever</i> is generally not very intense. The +temperature of the head, especially the forehead, is +considerably increased in all cases and remains so +until death ensues, while the feet have great tendency +to getting cold.</p> + +<p>The <i>pulse</i> is characteristic in many cases. In +the beginning of the disease the pulse is quickened<span class='pagenum'><a name="Page_37" id="Page_37">[37]</a></span> +only to slacken after a few days. The number of +beats may be reduced to 40–60 a minute (normal +90–100), however it does not commonly remain at +a certain figure, but varies, often inside of an hour, +so that at one time 40, then 60 and again 80 beats +may be counted inside of twenty-four hours.</p> + +<p>The pulse again increases 1–3 days before death +and then to such a rate that it is almost impossible +to count it. It may reach 180 and 200 beats a +minute. As soon as this rate of the pulse follows +one of the reductions described above a speedy death +may be predicted.</p> + +<p>Of great importance are the variations in respiration. +In the beginning stages of the disease breathing +is normal except in such case where tuberculosis +has made great progress in the lungs and in the case +of high fever. Then of course breathing becomes +more rapid. Acute hydrocephalus influences respiration +in such a way that it slackens and becomes +irregular. In one minute children may breath fifteen +times, in another thirty, then again 20 times; at one +time breathing may be very slight with almost invisible +expansion of the chest and without any noise +whatever, then again it may consist of deep sighs; +these are also characteristic of this particular disease. +Sometimes breathing is completely discontinued for +ten seconds and more.</p> + +<p><span class='pagenum'><a name="Page_38" id="Page_38">[38]</a></span>If the pulse attains that extreme rate shortly +before death the rate of breathing will also be increased.</p> + +<p>As regards the <i>skin</i>, the same is generally damp +from the beginning of the disease; severe sweats are +observed on the head; with progressing disease the +skin becomes dry, brittle, comes off in flake-like scales +and only when the death-predicting increase of the +pulse sets in, there appears a profuse sweat, the cold +sweat of death.</p> + +<p><i>Headache</i> is also a prominent and pretty nearly +constant symptom. As has been mentioned before, +it does not as a rule attend the precursory symptoms. +It generally begins with vomiting and soon +becomes so violent that older children constantly +cry aloud and lament, while the smaller ones put +their little hands up to their head, pull their hair and +ears and restlessly roll about on the pillow.</p> + +<p>These expressions of pain last as long as children +retain consciousness, a particular part of the head is +not commonly pointed out, but asked about it the +majority point to the forehead. With small children +automatic movements are noticed that also seem to +refer to headache, and which consist in rapidly +placing the hand on the head and then drawing it +back.</p> + +<p>The larger children complain of <i>pains in the +bowels</i>, especially in the region of the stomach,<span class='pagenum'><a name="Page_39" id="Page_39">[39]</a></span> +which remarkably often, though not regularly, become +more intense by pressing and may become so +violent that the children cry out aloud with pain, +when the stomach or other portion of the abdomen +is but slightly touched. But these pains do not last +as long as the headache, they often stop suddenly, at +times return.</p> + +<p>The shape of the <i>abdomen</i> is extraordinarily +characteristic. In the beginning nothing remarkable +can be noticed, but after the symptoms of acute +hydrocephalus, vomiting, constipation, etc., have +lasted for some time, the abdomen gradually decreases +in size, becomes wrinkled and collapses until +it finally assumes a scaphoid shape and by slight +pressure the large iliac artery can be felt on the +spinal column.</p> + +<p>This contraction of the abdomen is attendant in +every case of tuberculous meningitis.</p> + +<p>If the large <i>fontanel</i> on the head is not yet +closed, the same will gradually bulge out as the +disease progresses.</p> + +<p>The <i>mental activity</i> suffers premature derangements, +such as have been fully mentioned in the +description of the precursory symptoms. The most +striking is the confused, staring look, the peevish and +surly behavior, and again in other cases the extreme<span class='pagenum'><a name="Page_40" id="Page_40">[40]</a></span> +indifference toward otherwise well-liked persons and +things. Later on actual delirium sets in, but +generally of a quiet nature.</p> + +<p>A very common symptom is a loud, plaintive +outcry, that is repeated at longer or shorter intervals. +Children often cry out at partly regular +intervals during a whole night; these cries are always +accompanied by a loud sigh. These symptoms of +excitement being extremely tormenting and depressing +for the sympathizing relatives, fortunately last +no longer than 6–8 days at the most, and are succeeded +by a deep <i>stupor</i>.</p> + +<p>If the children have once become <i>unconscious</i>, +they do not recover again as a rule but remain so +until death; delirium and stupor may alternate with +each other in certain cases, but the former process +is by far the most frequent.</p> + +<p><i>Convulsions</i> appear only in the later stages. At +first the interval between the attacks are long, often +as many as three or four days intervene. Commonly +however they come much oftener and may in some +cases last for hours. All extremities are affected by +these convulsions, the eyes become red, are rolled in +every direction and turning way up are fixed so that +nothing but the whites is visible. After several +minutes, often after two or three hours, these general<span class='pagenum'><a name="Page_41" id="Page_41">[41]</a></span> +convulsions subside, the children, now very pale, drop +into a deep sleep and their general condition appears +much reduced.</p> + +<p>Different muscular groups especially those of the +face are subject to <i>local cramps</i>. The upper lip may +become distorted, convulsive smiles have been observed, +also peculiar sucking motions. The children +point their lips and flatten them again, sometimes +for hours in succession.</p> + +<p>In the latter stages a squinting of one or both +eyes may be noticed but this may again disappear.</p> + +<p><i>Grinding of the teeth</i> is another very peculiar +symptom which is well-known and feared by experienced +nurses. The <i>arms</i> are subject to various +motions, at times sweeping automaton like, then +again convulsive contractions, sometimes trembling +of the muscles, at others a throbbing of the tendons. +Many patients put their hands to their sexual +organs and make motions tending to onanism.</p> + +<p>The <i>legs</i> are not subject to cramps as much as +the arms; they are mostly bent and drawn up in a +half paralyzed condition.</p> + +<p>The <i>muscles of the neck and back</i> are very much +contracted and most children, when raised or laid on +their side, bend the head far back.</p> + +<p><span class='pagenum'><a name="Page_42" id="Page_42">[42]</a></span>In most children an extreme sensibility at being +touched is observed. They may be handled with the +greatest possible care and lifted most tenderly, a +slight pressure on the head, body or hands in changing +their position will be violently resisted with +obvious expressions of pain. In the latter stages +this extreme sensibility gives way to <i>insensibility</i>.</p> + +<p>Then the children may be pinched and poked, +they may be turned and moved from one side to the +other without any consideration, they will not resist +and only give expression to the remaining sensibility +by a low whimper. The lack of sensibility may be +especially marked in the eyes; these can be touched +with the fingers, without causing a closing of the +lids.</p> + +<p>The sense of <i>hearing</i> seems to continue its functions +until very late. Children show that they hear +as long as they are not completely unconscious; +even when addressed in a low tone of voice they +react somewhat. The sense of <i>smell and taste</i> also +are lost toward the very end of the disease.</p> + +<p><i>Paralytic</i> affections appear during the final +stages. It has been observed in some cases that the +arm and limb are paralyzed on one side only. Often +one upper eyelid is paralyzed and hangs down on +one side of the face and the muscles of the tongue +may be affected.</p> + +<p><span class='pagenum'><a name="Page_43" id="Page_43">[43]</a></span>Generally the patient dies after violent general +convulsions that last for hours. Exceptionally only +the paralytic symptoms increase gradually and +cause death without any agony or struggle, simply a +discontinuance of the functions constituting life.</p> + +<p>The duration of the disease varies from 2–4 +weeks from the beginning of the characteristic symptoms. +Generally the day when the children take to +the bed is fixed as the beginning of the disease.</p> + +<p>The former methods of treatment have been a +signal and absolute failure in every case. Every +child that has once been attacked with this disease +has heretofore died. Until now Koch has not been +able to make any experiments with acute hydrocephalus, +so that it remains an open question whether it +is now possible to cure this disease.</p> + +<p>Besides tuberculosis of the cerebral membranes +with which children are afflicted, <i>tuberculosis of the +brain</i> may occur, although this disease is very rare. +Tuberculosis of the brain appears in the shape of +small tumors in all parts of the brain. After +longer duration of tuberculosis of the brain, tubercular +meningitis appears.</p> + +<p>The process of this disease may be varied. In +some cases the development of cerebral tuberculosis +is manifested by the sudden appearance of high fever +temperatures or violent headache; to this may be<span class='pagenum'><a name="Page_44" id="Page_44">[44]</a></span> +added, slackening of the pulse, vomiting, stiff neck +and isolated cases of palsy; sometimes an attack of +convulsions is the first manifestation.</p> + +<p>In other cases the beginning can not be accurately +determined, as the beginning symptoms of the disease +are so slight as to escape notice. Impaired +process of nutrition, languor and headache are +symptoms from which the existence of some serious +affliction may be inferred without being able to +determine its nature in the earlier stages.</p> + +<p>Again in other cases the disease may proceed +through all its stages without any cerebral appearances +whatever. This is especially true of small +tubercles and of diseases of infants. However, we +more frequently observe in children than in adults +convulsions of varied intensity and distribution.</p> + +<p>Nutrition is more and more impaired as the disease +progresses, in isolated cases only, a temporary +improvement may be observed.</p> + +<p>The <i>end</i> of cerebral tuberculosis has been <i>death</i> +before this. Ten days to two weeks, even three weeks +may pass from the first appearance of tubercular +meningitis to the completion of the process of the +disease, attended by feverish motions characteristic +of this condition and by cerebral symptoms, first +with the character of excitement, later on with that +of palsy.</p> + +<p><span class='pagenum'><a name="Page_45" id="Page_45">[45]</a></span>The treatment of cerebral tuberculosis has been +entirely insufficient before this. Let us hope that it +will be possible to effect a cure by means of Koch's +new method.</p> + +<p><i>Tuberculosis of the Kidneys</i> is met with from the +earliest childhood till old age. Most frequently +the male sex is afflicted during manhood.</p> + +<p>In most cases tuberculosis also exists in other +organs, especially in the urinary and sexual apparatus. +The existence of pulmonary or intestinal tuberculosis +is not essential.</p> + +<p>The symptoms of renal tuberculosis are of such +general and indefinite character, that it is often impossible +to fully determine the disease. Now, however, +it will be more easily possible on account of +Koch's discovery.</p> + +<p>The <i>urine</i> may, but need not contain pus and +blood. Sometimes small lumps are found in the +urine.</p> + +<p><i>Pains</i> are only sometimes felt in the renal regions; +<i>fever</i> may be occasionally attendant.</p> + +<p>The disease lasts for months and years; though +before now it has inevitably resulted in death, though +it has in exceptional cases taken ten years or more.</p> + +<p>The internal treatment of renal tuberculosis was +ineffectual, surgical treatment has been attended<span class='pagenum'><a name="Page_46" id="Page_46">[46]</a></span> +with greater success. This consisted in removing the +diseased kidney. Now good results will possibly be +attained by the application of Koch's method to +cure and resource to surgery will be taken in exceptional +cases only.</p> + +<p><i>Tuberculosis of the suprarenal capsules</i> is of +very rare occurrence. It leads to a peculiar change +in the color of the skin; the same turns dark brown +or bronze color. Sooner or later death results.</p> + +<p>Perhaps the application of Koch's method will, +besides curing the disease, give us information regarding +the functions of the suprarenal capsules +about which nothing whatever is as yet known.</p> + +<p>A large space in the realm of disease is claimed +by <i>tuberculous affections of the bones and joints</i>. +These afflictions appear particularly in childhood +though manhood is by no means exempt. They may +appear in all portions of the body, although a +marked preference is shown for certain parts. Although +the tubercle-bacilli are infinitely small, they +possess the power to cause suppuration of the bones +and joints and to produce acute inflammation of +these parts.</p> + +<p>Most frequently tubercular affections of the +bones are found in the hip-joints, the knee and the +spinal column.</p> + +<p><span class='pagenum'><a name="Page_47" id="Page_47">[47]</a></span><i>Tuberculous inflammation of the hip-joint</i> is +principally a disease occurring in childhood; though +it rarely appears before the third year. It is most +frequent from the fifth to the tenth year.</p> + +<p>Inflammation of the hip-joint developes very +slowly in children, it generally takes months before +the slightest beginning symptoms reach a threatening +appearance. The first sign is <i>lameness</i>; among +laymen tuberculous inflammation of the hip-joints is +known as "voluntary limping."</p> + +<p>By limping we understand that mode of walking +in which one leg is spared and by this the trunk is +supported only a short time by one extremity and +all the longer by the other. In every painful affection +of the lower extremity limping results as the +weight of the body increases the pain. The lameness +in the case of diseased hip-joint has something +peculiar about it, inasmuch as not only a part of the +extremity but the whole of it is dragged. For this +very reason parents of children afflicted with inflammation +of the hip-joint use the expression "the +child draws" or "drags the leg".</p> + +<p>In the beginning even the examining physician +finds no symptoms of disease in the joint. No +swelling, no abnormal position, no restriction of the +freedom of motion, no pain from pressure or while +moving, in short nothing can be found that would +otherwise indicate the beginning of an inflammation +of the joints.</p> + +<p><span class='pagenum'><a name="Page_48" id="Page_48">[48]</a></span>Yet <i>lameness only</i> is sufficient data from which +we may infer the probable beginning of hip-joint inflammation. +It is much better to overestimate the +significance of this symptom than to miss the proper +time for calling in the aid of a physician by placing +too little confidence on it.</p> + +<p>The second symptom, <i>pain</i>, rarely attends the +beginning of lameness, generally it comes several +weeks later and in the case of very slow development +of tubercularly inflamed hip-joint several +months later. In very small children the attendance +of pain is manifested by the fact that they will not +play and they often wake up in the night and begin +to cry.</p> + +<p>Children from the fourth and fifth year upward +definitely point out the hip as the seat of pain, sometimes, +however, the knee-joint on the diseased side +is designated with great determination. This pain +in the knee has often been the cause of mistakes.</p> + +<p>Later on painfulness of the hip-joint is experienced +from pressure and at about the same time the +movements are impeded.</p> + +<p>Then the leg takes a peculiar position. The +thigh is slightly bent and rolls outward. For convenience +the child drops the half of the pelvis corresponding +to the diseased hip-joint, and naturally +raises the other half. From this apparently a curvature +of the spinal column results in the lumbar<span class='pagenum'><a name="Page_49" id="Page_49">[49]</a></span> +region. Apparently only, for when the child is laid +down and the morbid position of the thigh is restored +the curvature of the lumbar column disappears.</p> + +<p>During the further progress of the disease the +pain is increased, and the sensibility may become so +acute that the slightest movement of the limb, even +a shaking of the bed in which the patient lies will +cause the most intense pain. In the previous stage +walking could only be done for short distances and +then awkwardly, now it is entirely impossible. +Children are obliged to lie in bed night and day, and +under these altered conditions there is a change of the +position of the extremity. The increased sensibility +induces the child to seek the medium position, the leg +is bent more than in the position mentioned above, +it is halfway straightened.</p> + +<p>To this is added, that the child can not lie well on +the sensitive and swollen hip; with right side hip-joint +inflammation it turns on the left. As the diseased +and bent thigh does not then rest on the mattress +the same is placed on the healthy limb for support +and for protection from movements, in the same +manner as we lay one leg on the other in a healthy +condition when we sleep on our side.</p> + +<p>The actual danger to life in tuberculous hip-joint +inflammation begins with the time when the child +takes to his bed. The fatal end comes almost without +exception after suppuration has commenced,<span class='pagenum'><a name="Page_50" id="Page_50">[50]</a></span> +very rarely before that time. Total suppuration of +the hip-joint is an almost absolutely fatal process. +If this suppuration sets in suddenly, it may result in +an early death with attendance of acute fever. In +other cases several weeks may elapse from beginning +suppuration till death.</p> + +<p>A complete cure of tuberculous hip-joint inflammation +may come about spontaneously. But often +the knee remains bent and unserviceable for walking, +so that crutches or machines must be used.</p> + +<p>Even before this the beginning stages were +treated with fair prospects of success, and it is a +lamentable fact that in many cases the import of +these seemingly trivial symptoms has been underestimated.</p> + +<p><i>Rest</i> is of the greatest importance during the +very first stages of the disease in which the attending +symptoms are of so indefinite a character that it +is almost impossible to know whether hip-joint inflammation +will develop or not; the child must not +be allowed to walk. Aside from this the application +of brine-, malt- and sea-water baths is advised. An +abundance of nourishing food is of just as great +importance. All this will also retain its significance +in the future.</p> + +<p>Formerly recourse to surgery has been taken +during the later stages of the disease in which +suppuration of the internal parts of the joint has<span class='pagenum'><a name="Page_51" id="Page_51">[51]</a></span> +commenced and large parts of the diseased bones +may have become mortified. An incision is made +into the joint, the same is exposed and all diseased +portions are carefully removed. In the future this +operation must probably also be performed, although +with the difference that the prospects of +success are now much more certain than formerly +when relapses only too often followed the operation.</p> + +<p><i>Tuberculous inflammation of the knee-joint</i> is, as +said before, very frequent with children and is rather +lingering in the beginning. Here also a slight dragging +or limping of the diseased leg can be noticed. +The child when asked about the limping, or of its own +accord, complains of pain in the joint after walking +or when the part is pressed; at first nothing abnormal +can be seen on the knee by the layman.</p> + +<p>On closer examination, however, by comparing +the two knees it will be found that the grooves on +each side of the patella, which give the healthy knee-joint +the beautifully modeled shape, have nearly or +quite disappeared; nothing more can be noticed.</p> + +<p>The hinderance in motion may be so insignificant, +that the children may slightly limp about for +weeks and months and complain but little. Generally +the physician is not called until the limb begins to +hurt and swell after continued exertion.</p> + +<p><span class='pagenum'><a name="Page_52" id="Page_52">[52]</a></span>The swelling which in the beginning is hardly +noticeable is now more plainly visible, the knee-joint +is evenly rounded and quite sensitive to pressure.</p> + +<p>If the disease is not now properly treated, its +further course will be as follows: the patient may +perhaps linger for several months; then comes a +period when he must keep to his bed uninterruptedly +because moving results in too much pain; generally +the limb becomes more and more bent.</p> + +<p>Now particularly painful points appear on the +joint, especially on the inner or outer side or in the +bend of the knee; on one of these points a soft portion +distinctly developes, the skin becomes reddened +and finally suppurates from the internal parts outward +and breaks after a few months; thin purulent +matter mixed with flakes is discharged. The pains +now cease, and the condition is improved; but this +improvement does not last; soon another abscess +is formed and thus it continues.</p> + +<p>Meanwhile perhaps two or three years may have +elapsed; the general condition becomes greatly reduced. +The child, formerly strong and healthy, has +now become lean, the discharges of matter have +often been attended by acute febrile attacks; the +patient becomes exhausted, loses his appetite and digestion +becomes more impaired from week to week. +Even now a spontaneous change for the better is +possible, though this happens very rarely; more<span class='pagenum'><a name="Page_53" id="Page_53">[53]</a></span> +frequently the disease progresses and leads to death +from exhaustion resulting from severe suppuration +and continual attacks of fever.</p> + +<p>Restoration to health is indicated by decreased +suppurative discharges; the openings of the fistulae +contract, the general condition is improved, the +appetite is restored, etc. Finally the fistulae heal, +the joint becomes fixed at an angle or bent or otherwise +crippled, but painfulness disappears and the +patient escapes with his life and a stiff leg. This is +the most favorable result known to have been obtained +in severe cases. The joint may become a solid +bony immovable mass or may admit of slight movements. +The whole process may last from two to four +years.</p> + +<p>The former treatment of tuberculous inflammation +of the knee-joint was either of a general or a +local nature. The general treatment was designed +to strengthen and nourish, and will continue to be +applied in the future.</p> + +<p>The local treatment consisted in the application +of salves, brushing with tincture of iodine, spanish +fly plasters, wet and dry bandages. As with inflamed +hip-joint absolute rest by lying in bed is of +the greatest importance.</p> + +<p>If after a certain period of rest and application +of the above-named remedies no improvement in the<span class='pagenum'><a name="Page_54" id="Page_54">[54]</a></span> +state of health could be noticed, the diseased joint +was laid in plaster or confined with splints.</p> + +<p>If even then, after such treatment for months, no +improvement could be noticed but rather that the +general state of health was reduced, nothing remained +to be done excepting an operation, by which +all the diseased parts of the knee-joint were removed, +or amputation, that is, the taking off of the diseased +limb. The latter method was generally adopted in +the case of feeble and emaciated individuals and those +who had passed the age of early manhood, as with +these the removal of the diseased parts did not, as a +rule, result in an improvement of the general condition, +which was especially intended.</p> + +<p>Now tuberculous inflammation of the knee-joint +will be treated by Koch's method and in extreme +cases only will operation be necessary. At all rates, +an absolute cure will be easily effected.</p> + +<p>Aside from the hip- and knee-joint the <i>spinal +column</i> is most frequently attacked by tuberculosis. +Here also it is the youthful age, from the third year +upward, that has to suffer most from this serious +disease. Adults are rarely attacked by it and with +them it generally appears in connection with general +tuberculosis.</p> + +<p>The tubercle-bacilli penetrate into the substance +of the vertebrae, destroy the same and transform it +into purulent matter. As a result the destroyed<span class='pagenum'><a name="Page_55" id="Page_55">[55]</a></span> +vertebrae sink or rather settle down and cause a +curvature of the spine, in other words a humpback.</p> + +<p>In the beginning the symptoms of diseased spine +are very indefinite and misleading. The patient +rarely complains of pain at first, and it is only +noticed that the sick child easily tires of standing or +walking and tends to hold on to chairs and similar +objects with his hands to relieve the spinal column of +the weight. From such uncertain data it is of +course impossible to recognize the disease.</p> + +<p>Only then when the softened vertebrae give way +under the weight of the body, that is when the humpback +begins to develop, can tuberculous inflammation +of the spine be surmised with any degree of +certainty.</p> + +<p>As a rule two other characteristic phenomena +appear which are dependent on the pain in the +affected spinal column. The child, while standing, +places his hand on the thighs and thus directly supports +part of the weight of the trunk with the lower +extremities; at the same time he avoids bending the +spinal column forward. This anxious care for the +diseased vertebrae is especially noticeable when the +child attempts to pick up an object from the floor. +While the healthy child bends freely forward, the sick +one crouches down and while bending the knee and +hip keeps the spinal column as straight and stiff +as possible. Frequently a small spot on the spinal<span class='pagenum'><a name="Page_56" id="Page_56">[56]</a></span> +column is found to be extremely sensitive to pressure +in this stage; but such a subjective symptom must +be considered with caution especially with children.</p> + +<p>This humpback, which is a result of tuberculous +inflammation of the spine, must not be confounded +with the humpback caused by rickets. With the +latter the curvature is more uniform as a rule, and in +the start at least, disappears while in a horizontal +position. Besides the humpback resulting from rickets +appears between the first and fourth years of age, +while tuberculous inflammation of the spine rarely +begins before the fourth year. And finally rickets +never causes suppuration while this is always the +case with inflammation of the spine.</p> + +<p>The progress of suppuration is downward as a +rule and does not admit of examination until it gets +near to the surface of the body; before this the feverish +conditions toward evening are the only signs +that indicate beginning suppuration. Ardent fever +is not attendant during this time; the temperature +does not exceed 38 or 38.6° C. and even such trifling +increase of temperature may be wanting.</p> + +<p>As soon as the skin is reached by the originally +deepseated centres of suppuration, it gradually becomes +red and later on also suppurated. If the skin +is broken and the matter discharged, great care +must be taken to keep the wound clean, as otherwise +the suppurative cavities may suddenly become<span class='pagenum'><a name="Page_57" id="Page_57">[57]</a></span> +ichorous and lead to rapid death. In other cases +this extreme result is not caused and fistulae are +formed from which the ichor constantly flows. Small +bits of mortified and broken off bones may be +thrown out with the matter.</p> + +<p>As a result of the sinking and settling of the +vertebrae the spinal chord may suffer from pressure +and contusion as it is contained in a channel formed +by the vertebrae. Aside from certain pain it may +result in paralysis of certain parts.</p> + +<p>Formerly the diagnosis of tuberculous inflammation +of the spine in its beginning stages was very +uncertain. A great number of afflicted are at present +cured by surgical treatment; in former times this +was not possible, as the majority of patients died in +whose case the disease had progressed to suppuration. +But the curvature of the spine could not be +removed by any former treatment and can not be by +Koch's new method. Vertebrae once destroyed can +in no way be restored to their normal condition.</p> + +<p>Nevertheless the number of patients whose life is +spared will be a still greater one and the number of +complete cures will also be increased in a short time. +Formerly tuberculous inflammation of the spine was +treated as follows: the abscesses were opened and +antiseptics carefully applied: mechanical apparatus +and corsets were used to aid in a natural cure. +These apparatus will surely be of inestimable value +at the application of Koch's method.</p> + +<p><span class='pagenum'><a name="Page_58" id="Page_58">[58]</a></span>As has been stated before tuberculosis may +attack all other bones and joints and there cause the +most serious derangement. Formerly these tuberculous +afflictions were treated surgically or by means +of iodoform, which has produced pretty good results +in certain cases.</p> + +<p>However it will certainly be possible to produce +still better results with Koch's method of treatment, +especially in the restoration of the functions of +the afflicted parts. Here, as in all tuberculous affections, +it is particularly essential to subject the +respective case to treatment in as early a stage as +possible and before incurable destruction of the +tissues of the bones and joints have been caused.</p> + +<p>A certain disease of the skin called <i>lupus</i> (ringworm) +must be counted in with the number of diseases +generated by the tubercle-bacillus.</p> + +<p>Lupus may begin in two different ways. Either +in the form of a purple spot, which is raised above +the level of the skin and which has no definite limits +but blends with the healthy parts; or as a slightly +raised, moderately firm, darkred grain, sharply +limited and about the size of a pinhead or millet +seed.</p> + +<p>If the disease has begun in the shape of spots, the +afflicted portions of the skin gradually swell during +the process of the disease. Several isolated knots +appear around which the disease spreads more and +more.</p> + +<p><span class='pagenum'><a name="Page_59" id="Page_59">[59]</a></span>While the disease thus takes possession of greater +area and developes new centers, a uniform scaling off +of all knots begins.</p> + +<p>After prolonged existence, sometimes after short +duration, decay and casting off of the epidermis in +its entire thickness supercedes the scaling process, +and suppuration transforms the ringworm into an +ulcer covered by a dirty-brown rind and disagreeably +colored serum.</p> + +<p>The ulcers of lupus are of various, generally +irregular shape, the rims not hard, the ground flat +and covered with purulent matter and decayed tissue; +they are commonly surrounded by a faint reddish +areola. These ulcers gradually become epulotic and +form irregular, generally slightly protruding white +scars in which new tubercles may appear.</p> + +<p>Lupus appears most frequently in the face and +especially frequent on the nose. Sometimes its appearance +is indicated only by an inflammation and +swelling of the mucous membranes of the nose and +at the same time a reddening of the epidermis. The +nostrils are stopped up by a thin rind which, if torn +off, is replaced by a thicker one below which an ulcer +is formed that spreads with greater rapidity on the +mucous membranes of the nose than on the external +epidermis of the same.</p> + +<p><span class='pagenum'><a name="Page_60" id="Page_60">[60]</a></span>Sometimes the whole process on the nose is so +rapid, that very often the physician is not called +to the patient, before a large part of the wing of +the nose or of the nasal epidermis is destroyed and +deep ulcers have developed under the rind. New +tubercles of lupus are commonly noticed to spring up +on the margins of these ulcers; the cartilage as a +rule resists the progress of the disease for a longer +period and may be unhurt, while the skin on the +wing of the nose may be completely destroyed.</p> + +<p>Frequently the process is extended to the mucous +lining of the hard palate and to the gums. Lupus +generally appears on the lips in the same manner as +in the nose. The upper lip especially appears very +much swollen and covered with ulcers after a +prolonged existence of the affection. Sometimes even +the aperture of the mouth itself is reduced in size by +the development of ulcers and scars on the surrounding +parts.</p> + +<p>If the process extends to the lower eyelid, the +connective tissue as a rule becomes much swollen and +reddened. The malady especially attacks the inner +angle of the eye, destroys the entrance of the lachrymal +duct, and from there the lupous tubercles +appear on the connective tissue. Gradually +tubercular formations develop on the cornea and +sight becomes impaired.</p> + +<p><span class='pagenum'><a name="Page_61" id="Page_61">[61]</a></span>On other parts of the face lupus generally appears +in the form of small knots, about the size of millet +seeds, which remain for a time then multiply and +spread. The epidermis swells between these knots +and irregular ulcers develop on a hard swollen and +glossy ground, and are covered by dark brown +rinds.</p> + +<p>Tubercles appear anew on the margins of the +ulcers and in the spaces between them, isolated whitish +spots of sunken or raised scab tissue are observed +on which very frequently lupous tubercles again +develop.</p> + +<p>Lupus appears on the throat, neck, back, breast, +and the extremities, most frequently in serpentine +form i. e. swellings of the skin develop, being +arranged in curves, they progress in the same manner, +these are transformed into just so many ulcers. +Between these whitish scarred spots are noticeable on +which small red lupous tubercles again appear.</p> + +<p>Lupus is more frequently found on the extremities +than on the trunk. The surface of the skin is +found to be tense and glossy on a firm base which is +affected by lupus.</p> + +<p>Deep ulcerous formations of lupus are sometimes +observed on the fingers and toes, particularly on the +finger-joints, these may at times penetrate into the +inner parts of the joints, secreting whitish pus and +covered with a thick rind.</p> + +<p><span class='pagenum'><a name="Page_62" id="Page_62">[62]</a></span>As regards the difference between lupus and syphilitic +diseases it has been found that lupus commonly +developes before puberty while syphilis appears in +the mature age.</p> + +<p>The ulcers of lupus are often round like those of +syphilis with sharply defined margins, but at the +same time they are flat accompanied by little or no +pain; rim and base of the same are loose, red, rank, +and bleed easily. On the other hand syphilitic ulcers +are very painful and rim and base are covered with +greasy matter.</p> + +<p>Lupus appears only in the form of knots, which +are deeply inbedded, from size of a pinhead to that +of a lentil, but never as large knots in the beginning. +Syphilis produces large and palpable knots +from the start.</p> + +<p>Loss of the bony part of the nose or destruction +of the hard palate are observed, but rarely and after +protracted existence of lupus, and often in the case of +syphilis.</p> + +<p>The indicated peculiarities however refer only to +typical cases of lupus and of syphilis. In other cases +it was almost impossible to show a difference.</p> + +<p>As regards the course of lupus, the same begins, +as has been stated before, in earliest childhood, sometimes +only in the form of scaly spots and knots. +Less often lupus developes after complete development<span class='pagenum'><a name="Page_63" id="Page_63">[63]</a></span> +of manhood. It is more frequent with women +than with men. Sometimes some of the knots remain +isolated and disappear again after a time; in other +cases additions appear in the course of time, which +may affect larger portions of the body and lead to +more or less dangerous ulcers. As a rule the course +of lupus, even of great extent, is not malignant and +at the most the alliance with <i>traumatic erysipelas</i> +and possibly the appearance of <i>pulmonary consumption</i> +may succeed the affliction. In cases of +not too rare occurrence it has been observed that +lupus has developed into <i>cancer</i>, which has always +resulted fatally.</p> + +<p>The <i>treatment</i> of lupus has principally been a +<i>local</i> one. Caustics were applied to destroy lupous +tubercles by direct action, and furthermore recourse +has been taken to the so-called mechanical treatment, +in which the ringworm was scraped out.</p> + +<p>Our experiences relating to the mechanical treatment +of lupus have taught us the following.</p> + +<p>Lupus can not be cured without destroying and +removing the diseased and affected tissue. That +method which effects the most radical destruction, +protects most from relapses. Therefore the best +method of treating lupus is to cut out the diseased +skin. But with the superficial spreading peculiar to +many cases of lupus this method can only be applied<span class='pagenum'><a name="Page_64" id="Page_64">[64]</a></span> +within certain limits. Then again the secondary +growths after an operation may be of serious consequences.</p> + +<p>Unfortunately it has not been possible before this +to remove all diseased portions, no matter what +method was applied, because often tiny lupous tubercles +spring up which are almost invisible to the +naked eye. These tubercles will again be the starting +point for another spreading of lupus.</p> + +<p>We will see that Koch's new method to cure has +the advantage both to make visible all tubercles, +even those that have escaped our notice and also to +effect a cure in the shortest time even in old chronic +cases that have before this been considered incurable. +It is especially possible in this form of tuberculosis +to follow the specific action of the new remedy, as we +will learn later on.</p> + +<p><i>Tuberculosis of the testicles</i> is not so very rare, +it is found in about 2<small><sup>1</sup></small>⁄<small><sub>2</sub></small> per cent. of all men afflicted +with pulmonary consumption. It is more rarely met +with in children than in men.</p> + +<p>The conditions under which tuberculosis of the +testicles and epididymis developes are various inflammatory +processes with existing disposition. It +is mostly gonorrhea or some other inflammation of +the urethra, or injured testicle. It occurs less frequently +without any apparent cause.</p> + +<p><span class='pagenum'><a name="Page_65" id="Page_65">[65]</a></span>According to the starting point of tuberculosis +the symptoms are varied. If it starts in the testicle, +this appears normal or larger in size, but never +reaches extraordinary dimensions. The surface of +the testicle is at first smooth in the case of increased +tension, later only does it become irregular, bumpy +and of unequal consistency.</p> + +<p>If the starting point is in the epididymis, hard, +rounded lumps are formed generally in the head or +tail of the epididymis, rarely in the body. These +increase in size and cause a swelling often of extraordinary +dimensions, the surface of which appears +hard, irregular, bumpy and in certain parts yielding +and elastic. If the process is extended to the testicle, +this also increases in size. Then both together form +an oval swollen mass and can not be distinguished +from each other.</p> + +<p>Striking changes appear only later and consist +in the softening of the lumps and in the development +of abscesses.</p> + +<p>Very soon the lobuli are affected. The same are +then thickened in the septa, are hard and form an +irregular, bumpy swelling surrounded by more or +less thickened tissue.</p> + +<p>Very soon tuberculous changes are caused in the +prostate gland, an organ situated near the intestine +and the functions of which are to dilute the semen.<span class='pagenum'><a name="Page_66" id="Page_66">[66]</a></span> +A hardening is often the first sign, this is followed by +increase in size and then softening.</p> + +<p>With the affection of the prostate gland, that of +the urethra also begins, which passes through the +middle of the prostate gland. This disease often +appears in the form of a yellowish secretion, which is +more and more increased and becomes ichorous with +the decay of the urethra and the prostate gland. +This secretion must be distinguished from that which +as a venereal affection caused the whole process. +The tubercular derangements do not only extend forward +but also upward. The bladder, the ureters +and the kidneys are affected and show extreme +derangements with altered urinal secretions and +excretions.</p> + +<p>Of other symptoms of tuberculosis of the testicles +pain deserves especial mention. The same is slight +in the beginning, but often becomes insufferable.</p> + +<p>The symptoms here related often increase very +slowly. Essential changes are caused during the +chronic course of tuberculosis of the testicles if suppuration +sets in. The skin is perforated and fistulae +are formed. If there is no halt in the process, +general tuberculosis results and this has until now +always caused death.</p> + +<p>According to the time in which the general +derangements come about, a chronic and acute<span class='pagenum'><a name="Page_67" id="Page_67">[67]</a></span> +tuberculosis of the testicles has been distinguished. +The former is the more frequent, the latter of rare +occurrence.</p> + +<p>The sexual functions may remain unchanged if +only one testicle is diseased, but are generally ruined +if both epididymes are affected, because the secretion +of the semen is then interrupted by the stopping up +of the vas deferens. In some cases the sexual function +may be interrupted for a time only and may +then be resumed.</p> + +<p>The treatment before this has been surgical, in +which the diseased parts were carefully removed, and +where this was impossible, even castration (removal +of the testicle) was performed. Without doubt +Koch's method will cause great changes in the +method of treatment here also.</p> + +<p>Finally we must include in our reflection the well-known +disease of children, <i>scrofula</i>. Although the +same is not a form of tuberculosis in the sense of the +diseases just considered, still tuberculosis and scrofula +have the most intimate relations. Scrofula is +only too often a precursory stage of tuberculosis.</p> + +<p>The manifold scrofulous affections, such as inflamed +eyes, diseased ears, skin diseases, catarrh of +the nose, pharynx or bronchials, inflammation of +the joints and suppuration are not caused through +the cooperation of tubercle-bacilli. But here the<span class='pagenum'><a name="Page_68" id="Page_68">[68]</a></span> +same find an excellent soil for growth and propagation, +and they use the same to the full extent and so +give the impetus for the development of tuberculosis.</p> + +<p>Scrofula is one of the most frequent diseases, +it is spread over the whole world. It occurs more +seldom in the tropics than in the north. Furthermore +it is more frequent in a cold and damp climate +than in a dry one. Elevation has no influence on the +development of this disease. Scrofulous individuals +are found in the mountains as well as in the plains.</p> + +<p>Scrofula principally attacks children; it occurs +most frequently in the time from the second to the +fifteenth year. Rarely earlier developed scrofula +drags beyond the age of puberty or more advanced +manhood. Sex has no particular influence on the +development of scrofula.</p> + +<p>In many cases this particular disease is <i>inherited</i>. +The following causes are considered in the inheritance +of scrofula: great age, close relationship and +infirmity of the parents; but the germ of scrofula is +planted in the child by parents that are themselves +afflicted with tuberculosis or scrofula. This is most +frequently observed in children that have descended +from parents, who were scrofulous in their youth +and remained so, or that became tuberculous later +on and at the time of generation were afflicted by +advanced scrofula or tuberculosis, or that were<span class='pagenum'><a name="Page_69" id="Page_69">[69]</a></span> +suffering from oft-treated but never entirely cured +syphilis. Some scientists claim to have observed the +inheritance of scrofula by children, whose parents at +the time of generation were afflicted with tuberculosis +or were suffering from general debility resulting from +hunger and want.</p> + +<p>In the majority of cases scrofula is acquired, as a +rule the development of this disease is favored by +indigence and poor hygienic conditions according to +the coinciding experience of all scientists; <i>nutrition</i>, +especially in the first year of life, has the greatest +influence on the origin of scrofula.</p> + +<p>In <i>infancy</i> the most frequent cause of scrofula is +the premature giving of <i>farinaceous</i> food besides the +mother's milk, or the feeding of children with so-called +pap, especially when this is done in the <i>first +month of their life</i>.</p> + +<p>In later months the excessive eating of bread, +potatoes or vegetables instead of milk has an injurious +effect.</p> + +<p>Furthermore the development of scrofula is +favored by the breathing of <i>foul damp air</i> such as is +frequently found in newly built or damp houses and +also by <i>deficient care of the skin</i>.</p> + +<p>Scrofula thrives in the narrow tenement dwellings +in which is found a close, overheated, foul air +pregnant with smoke, kitchen fumes and mustiness +from the damp walls.</p> + +<p><span class='pagenum'><a name="Page_70" id="Page_70">[70]</a></span>Frequently the development of scrofula has been +observed to succeed measles, diphtheria, scarlatina +or whooping-cough.</p> + +<p>The opponents of vaccination also designate +vaccination as a frequent cause of scrofula. It is +supposed that a poison is transferred into the +system with the lymph which is enabled to generate +the phenomena of scrofula. However the supposition +has not as yet been proven.</p> + +<p>Of course the fact cannot be denied, that cases +of developing scrofula have been at times observed +as succeeding vaccination. But the circumstances +are the same as in the case of the contagious diseases +mentioned above. No one will probably maintain +that in those cases in which the development of +scrofula had been succeeding those diseases, that +this has resulted from a poison generated by the preceding +disease.</p> + +<p>The attempt to designate symptoms by which to +recognize a scrofulous constitution has at all times +been made. Many physicians have for a long time +distinguished a <i>torpid</i> and an <i>erethistic</i> scrofulous +constitution.</p> + +<p>With a <i>torpid</i> constitution the body is pale, +spongy and bloated, the nose and lips are thick, the +abdomen swelled, there is plenty of fat and but weak +muscles. Such children are indolent, at times peevish +and indifferent, they do not sleep quietly, have no<span class='pagenum'><a name="Page_71" id="Page_71">[71]</a></span> +appetite or may be voracious and suffer from derangements +of digestion. An examination of all +organs indicates no change. The children are easily +afflicted with eruptions of the skin, with inflammation +of the eyes and ears, and catarrh of the mucous +membranes, which are characterized by great obstinacy. +The derangements in nutrition here described +are caused by the lymphatic glands though a swelling +of the same can not be found.</p> + +<p>In the case of <i>erethistic</i> scrofula the children are +found to be of slight and lean structure, with fine +hair and long eyelashes; they are active, easily +excited, gifted and extremely sensitive to physical +pain. The face is pale and becomes easily flushed by +physical or emotional excitements. They are easily +subject to palpitation and short breath; and are +attacked by high fevers from the slightest reason. +The lymphatic glands, especially the deepseated ones, +are as a rule more or less swelled.</p> + +<p>In most cases, however, the characteristics of +these two forms are blended.</p> + +<p>The phenomena of scrofula are manifold and +extend over the entire body.</p> + +<p>The <i>skin</i> is frequently the seat of scrofulous +affections. These are particularly found on the head +and face and are characterized by great obstinacy +and tendency to return.</p> + +<p><span class='pagenum'><a name="Page_72" id="Page_72">[72]</a></span>Most frequently herpes appear, the parts especially +affected are the scalp, face, auricular passages, +eyelids and the nose with its surrounding parts.</p> + +<p>Pustules are sometimes developed under the skin +and may appear in great numbers. These pustules +may either break through the skin or shrink into a +caseous mass.</p> + +<p>Of all <i>mucous membranes</i> that of the <i>nose</i> +becomes most frequently diseased; in a great number +of cases this happens in the form of a chronic +catarrh; the mucous membrane of the nose is reddened +and swollen and a profuse, thick, purulent, +ichorous and easily drying fluid is secreted. Often +the external parts of the nose are swollen as a result +of the catarrh and the nostrils are stopped up with +thick yellowish-green rinds. Inflammation of the skin +is caused by the flowing out of the purulent and +ichorous liquid secreted.</p> + +<p>In many other cases the disease appears in the +form of scrofulous ulcers on the mucous membranes +of the nose; in such cases it is found that the nose is +stopped up with numerous yellowish brown crusts; +after removing the same the mucous membrane +appears swollen and moderately reddened, on several +places ulcers, the size of lentils, are found which are +covered with a yellowish gray coating. At the +slightest touch bleeding of the nose is caused; often<span class='pagenum'><a name="Page_73" id="Page_73">[73]</a></span> +also the external parts are reddened and swollen. +In such cases erysipelas frequently developes, starting +from the nose and spreading over the whole +face. Frequently a repetition of erysipelas occurs.</p> + +<p>The scrofulous catarrh just described is generally +of a very protracted nature and is marked by many +relapses. Sometimes the fluid secretion of the nose +is of very bad odor.</p> + +<p>The mucous membrane of the <i>throat</i> becomes +diseased at the same time as that of the nose. The +same is found to be moderately reddened and +swollen; the lymphatic glands especially those on +the posterior wall of the throat are increased to +swellings the size as large as peas. The <i>tonsils</i> also +become inflamed frequently and become enlarged +through the repeated rather chronic inflammation.</p> + +<p><i>Inflammations of the ear</i> are a common occurrence +with scrofula. These originate most frequently +by means of the eustachian tube, which connects the +ear with the back part of the mouth as a result of +the catarrh of the nose and throat. In a majority of +cases the inflammations of the ears lead to perforation +of the tympanum and may even result in fatal +cerebral meningitis.</p> + +<p>The <i>eye</i> is as frequently affected by scrofula. +Swelling of the lids and inflammation of the glands +are the lighter forms. Pustules on the connective +tissue of the eye and on the cornea, accompanied<span class='pagenum'><a name="Page_74" id="Page_74">[74]</a></span> +by photophobia, cramp in the lids and +flowing of tears are those severe forms that are so +frequently observed in scrofula, and that often leave +opaque and incurable spots on the cornea of the eye.</p> + +<p>Swelling of the <i>glands</i> has at all times been a +characteristic phenomenon of scrofula. A swelling is +merely the result of diseases of the mucous membrane +of the throat or nose, of herpes of the scalp +or face, of inflammations of the ears, eyes, periosteum, +bones, etc. In the beginning the swelling of the +glands is painless and results in flat swellings of +about the size of filberts, which may be moved back +and forth; such glandular swellings may exist for +years, without showing the slightest alterations.</p> + +<p>With renewed attacks they enlarge and may +become of considerable size. At times single glands +become inflamed, hurt when pressed and develop +abscesses which perforate the skin after it has +become inflamed and reddened.</p> + +<p>These abscesses may heal within a few days. In +the majority of cases, however, they remain for a +longer period, months and even years and result in +the well-known tumid, hard and immovable scars.</p> + +<p>Inflammation of the periosteum and of the bones +is one of the instances of scrofula. Most frequently +<i>spina ventosa</i> is found; the same consists of a +gradual, painless swelling of the diseased bones, +most frequently on the fingers and toes, so that they<span class='pagenum'><a name="Page_75" id="Page_75">[75]</a></span> +become bottle-shaped. The skin covering these +swellings is pale and tense. The swelling may +gradually disappear or begin to suppurate. Besides +this hip- and knee-joint inflammation are observed, +also inflammations of the ankle, elbow-joint, spine, +etc.; especially in the case of diseased bones it is +extremely difficult to fix a dividing line between +scrofula and tuberculosis.</p> + +<p>The frequence of anaemia with scrofula is only a +<i>result</i> of the disease and not a symptom. As a +result of scrofula nutrition and assimilation become +impaired, mostly in the cases of extreme suppuration.</p> + +<p>Scrofula is a chronic disease. In many cases it is +completely cured, the lighter cases after several +months and the more malignant after several years. +Extreme scrofula may often remain until puberty +and may be completely healed.</p> + +<p><i>Fatal</i> results are due to scrofulously diseased +bones, joints or glands, and it can not be denied +that a large number of children succumb in this +manner. Fatal results may also be due to additional +diseases, such as pneumonia, pleurisy, intestinal +catarrh, etc.</p> + +<p>It has been frequently observed that <i>tuberculosis</i> +succeeds scrofula. It is a well-known fact that +scrofula furnishes the largest contingent for tuberculosis.</p> + +<p><span class='pagenum'><a name="Page_76" id="Page_76">[76]</a></span>As a precautionary measure against scrofula a +careful regulation of the diet is recommended. +During the first nine months of life children should +be fed with human milk exclusively if possible. If +scrofula is hereditary in a family, or if the mother +exhibits symptoms of the disease, she should not be +allowed to nurse the child but a strong and healthy +nurse should be engaged. Recourse to artificial +nourishment must only then be taken, when nursing +the child is absolutely impossible. For this purpose +exceptionally pure cow's-milk ought to be +selected. All substitutes, that appear under various +names, such as infant's food, condensed milk, etc., +contribute much toward the development of +scrofula.</p> + +<p>Children 1–2 years of age are to be fed with +milk, meat and eggs. Only strong children, that +show no sign of scrofula may be fed once or twice a +day with small quantities of rice, tapioca, sago, +green vegetables, pulse, etc., beside the food above +mentioned.</p> + +<p>To prevent scrofula it is essential not to give the +food of adults to children during the first years of life; +avoid exclusively solid food and prepare the same in +a pappy form as much as possible. Of course a +proper regulation of meal-time and a careful avoidance +of overfeeding is by all means to be observed.</p> + +<p><span class='pagenum'><a name="Page_77" id="Page_77">[77]</a></span>It is of no less importance for a successful treatment +of scrofula to provide surroundings of as +favorable conditions as possible.</p> + +<p>First of all <i>pure air</i> containing plenty of <i>oxygen</i>. +Therefore the <i>sea-coast</i> is recommended as a proper +place for scrofulous children. The children ought to +stay there until the signs of scrofula have disappeared +and the entire nutrition has been improved. The +results obtained in the sanitary stations (vacation +colonies) along the sea-shore for scrofulous children +have received much favorable comment.</p> + +<p><i>Mountain air</i> has a similarly favorable effect +especially when <i>salt water baths</i> are used at the +same time; even the plain, pure <i>country air</i> proves +beneficial to scrofulous children. <i>Very dry</i> locations +and dwellings ought to be selected. The children +should remain <i>out of doors</i> as much as possible.</p> + +<p>Of great importance for scrofulous children, +furthermore, is a suitable course in <i>gymnastics and +rubbing-down with cold water</i>. To begin with the +water may be 72° but should gradually be reduced +to the natural temperature of well water.</p> + +<p>Just how far Koch's new method will take the +place of former remedies used for scrofula can not be +told at present as experiments in this direction are +wanting. Nevertheless it will be possible to prevent +the dangerous transition of scrofula into tuberculosis +and thus save the lives of a great many persons.</p> + +<p><span class='pagenum'><a name="Page_78" id="Page_78">[78]</a></span>Anyone who has informed himself through the +foregoing as to the great number of diseases and +forms of disease that are directly or indirectly +connected with tuberculosis, will now be able to +estimate the farreaching import of Koch's discovery. +It will now be clear to him that pulmonary consumption +constitutes only a part, although a great +part of tuberculosis and that there are a great many +diseases besides that can now be surely cured, it is +hoped, with the aid of Koch's method. But this +much should be remembered by everyone that this +remedy also acts best and surest during the <i>beginning</i> +of a disease. We hope that no one will allow +valuable time to slip unimproved; it may easily +happen that it is too late for successful treatment. +Everyone will be able to recognize the symptoms of +diseases, which Koch has taught to cure, from the +foregoing complete description, and it is better to +apply the remedy once too often than miss the +proper time for application.</p> + +<p>Koch's first communications relating to the +subject have just been published and will be given +unabridged in the following pages. As these communications +are written for physicians we will add +such explanatory notes as are deemed essential for +general intelligence.</p> + +<div class="figcenter" style="width: 550px;"> +<img src="images/f03_550.jpg" width="550" height="321" alt="Tr. Koch in his laboratory" /> +<div class="caption">DR. KOCH IN HIS LABORATORY</div> +</div> + + +<p><span class='pagenum'><a name="Page_c1" id="Page_c1">[c1]</a></span></p> +<h2><a name="THE_FIRST_COMMUNICATION" id="THE_FIRST_COMMUNICATION"></a>THE FIRST COMMUNICATION<br /> +<i><span style="font-size:80%">Relating to a Method to Cure</span></i><br /> +TUBERCULOSIS,</h2> + +<p class="center" style="margin-top:2em; margin-bottom:2em; line-height:2.5em;">BY<br />Prof. R. KOCH, Berlin.</p> + + +<p>In a lecture, delivered by me several months ago, +at the International Medical Congress, I referred +to a remedy, which makes animal subjects impervious +to the inoculation of Tubercle-bacilli, and in the +case of diseased animals, checks the progress of the +tuberculous disease. In the meantime experiments +have been made with human subjects, about which I +will report in the following.</p> + +<p>Originally I intended to complete my investigations +and especially gain sufficient experience concerning +the practical application of the remedy and +its production on a larger scale before I published +anything concerning it. In spite of all precautions +too much has already been published about it, and<span class='pagenum'><a name="Page_c2" id="Page_c2">[c2]</a></span> +that distorted and exaggerated, so that I was obliged, +in a way, to prevent false conceptions, to give +even now a synopsis of the method as far as it has +progressed at the time being. Under present circumstances +it must necessarily be short and leave unanswered +many important questions.</p> + +<p>The experiments have been, and are still being +made under my direction by Dr. A. Libbertz and +Stabsarzt Dr. E. Pfuhl. The necessary subjects and +material have been provided by Prof. Brieger from +his Polyclinic, Dr. W. Levy in his Private Surgical +Clinic, Geheimrath Fraentzel and Oberstabsarzt R. Koehler +in the Charite-Hospital, and Geheimrath +Herr v. Bergmann in the Surgical University Clinic. +To all these gentlemen and their assistants I here +tender my heartfelt thanks for their untiring interest +which they manifested for this subject and also for +the disinterested help and aid which they have offered +at all times and without which it would have been +impossible for me to make such progress in a few +months in this difficult and responsible investigation.</p> + +<p>As my work is far from being completed, I can +not as yet make any statements relating to the +origin and preparation of this remedy and reserve +these for some future time.<a name="FNanchor_1_1" id="FNanchor_1_1"></a><a href="#Footnote_1_1" class="fnanchor">[1]</a></p> + +<p>The curative is composed of a clear brown fluid, +which in itself is not perishable, even without special<span class='pagenum'><a name="Page_c3" id="Page_c3">[c3]</a></span> +precautionary measures. For use this fluid must be +more or less diluted and these dilutions are perishable +when made with distilled water; Bacterian vegetation +soon develops in them and they become turbid +and are no longer fit for use. To prevent this the +dilutions must be sterilized through heat and be kept +under cotton batting or be prepared with a 5 per +cent. phenol solution which is much simpler. Through +repeated heating as also through the mixture with the +phenol the efficiency of the diluted solution appears +to be curtailed after a time and for that reason I +have always used solutions as fresh as possible.</p> + +<p>The remedy does not act through the stomach; +to effect a reliable action it must be applied subcutaneously. +For our experiments we have exclusively +used a syringe decided upon by myself for +bacteriological purposes, which is supplied with a +small india-rubber ball and which has no stamp. +Such a syringe can be easily kept positively aseptic +by rinsing with absolutely pure alcohol and on this +we base the fact that not a single abscess has sprung +from over a thousand injections.</p> + +<p>After trying various parts of the body as places +for application we selected the skin of the back +between the shoulderblades and in the lumbar +region, because at these places the injection was +almost painless and caused the least and in most +cases no local reaction.</p> + +<p><span class='pagenum'><a name="Page_c4" id="Page_c4">[c4]</a></span>Even at the beginning of our experiments we +found that in one particularly important point the +human subject was affected by the curative in a way +decidedly differing from that of the animal subject +generally used, the guinea pig. Therefore another +confirmation of the rule for experimentors upon +which hardly enough stress can be laid, not to rely +upon a like effect upon the human being from the experiments +on the animal without further confirmatory +inquiry.</p> + +<p>Man proved himself much more sensitive to the +effects of the remedy than the guinea pig. Up to +two cubic centimeters and even more of the undiluted +fluid could be injected under the skin of a healthy +guinea pig without causing any particularly disparaging +effect. In the case of a fullgrown man on the +other hand, 25 ccm. are sufficient to produce intense +results. In proportion to weight of body therefore +<small><sup>1</sup></small>⁄<small><sub>1500</sub></small> of the amount which has no noticeable effect on +the guinea pig has a decidedly strong effect on the +man.</p> + +<p>From an injection that I have made on my upper +arm I have experienced the symptoms which arise in +man after an injection of 25 ccm., in short they were +the following: Three or four hours after the injection +a raking pain in the joints, languor, inclination to +cough, oppressed breathing, which rapidly increased; +in the fifth hour I experienced intense chills which<span class='pagenum'><a name="Page_c5" id="Page_c5">[c5]</a></span> +lasted nearly an hour, at the same time nausea, +vomiting, increase of the temperature of the body to +39.6° C. After about 12 hours all these affectations +ceased. The temperature sank and reached the +normal height the next day. Heaviness of the limbs +and languor lasted for a few more days, and for the +same length of time the place of injection remained +red and painful.</p> + +<p>The lower limit of effect of the curative for a +healthy man is about .01 ccm. (= 1 cubic centimeter +diluted with a 100 parts) as numerous trials +have shown. The majority reacted on this dose with +only light pain in the joints and passing languor. +With a few a slight rise in temperature set in, to +38° C. or a trifle higher.</p> + +<p>Although there is a marked difference as regards +the dose of the curative (according to relative weight +of body) between the animal subject and man, an +evident resemblance is shown in several other +qualities.</p> + +<p>The most important of these qualities is <i>the +specific action of this remedy on tuberculous processes +of whatever kind they may be</i>. I will +not relate the effects on the animal subject in +this connection, as it would lead too far, but will +at once turn to the peculiar effects on tuberculous +human beings.</p> + +<p><span class='pagenum'><a name="Page_c6" id="Page_c6">[c6]</a></span>As we have seen, a healthy man reacts but little +or not at all on .01 ccm. The same is true of diseased +persons, provided they are not tuberculous. But the +relations are entirely different with those afflicted +with tuberculosis; a marked general and also a local +reaction resulted from an injection of the same +dose of the remedy (.01 ccm.)<a name="FNanchor_2_2" id="FNanchor_2_2"></a><a href="#Footnote_2_2" class="fnanchor">[2]</a>.</p> + +<p>The general reaction consists of an attack of +fever, which, beginning mostly with chills, raises the +temperature to over 39°, often up to 40° and even +41°. Other noticeable symptoms are pains in the +joints, a tendency to cough, great languor, and often +nausea and vomiting. Several times we observed a +faint icteric coloring and in some cases the appearance +on neck and breast of an exanthema resembling +measles. As a rule the attack begins 4–5 hours +after the injection and lasts 12–15 hours. In exceptional +cases it may begin much later, but then it is +not nearly so intense. The patients experience remarkably +little weakness from the attack and feel +relatively well as soon as it is over, generally better +than they did before it came on.</p> + +<p>The local reaction can best be observed on those +patients whose tuberculose affection is plainly visible, +for instance those afflicted with lupus. In them +changes take place that prove the specific antitubercular +action of the remedy in a most surprising way. +The diseased portions of the skin in the face, etc.<span class='pagenum'><a name="Page_c7" id="Page_c7">[c7]</a></span> +begin to swell and turn red even before the attack of +chills set in, although the injection is made under the +skin of the back, a point decidedly remote from the +affected parts. The swelling and reddening increases +during the fever and can attain a very marked degree +so that the lupus-tissue turns reddish brown +and necrotic. In the case of more sharply defined +lupus centres the more swollen and dark red parts +were edged by a white seam nearly a centimeter wide +and this again was surrounded by a wide bright red +border. The swelling of the diseased parts gradually +decreases after the cession of fever and may +have entirely disappeared after 2 or 3 days. A +serum exudes from these lupus-centres and, drying, +forms a crust on them which changes into scabs that +fall off in 2–3 weeks and sometimes leave a smooth +red scar after a single injection. Generally several +injections are necessary to effect a complete removal +of the lupose tissue, but of this I will speak further +on. It is very important to note that the changes +during this process are exclusively limited to the +portions of the skin affected by lupus; even the +faintest and smallest bits of diseased tissue go +through the entire process and become visible on +account of their swelling and reddening, while the +actual scab-tissue in which the various stages of +lupus have been completed remains unchanged.</p> + +<p>The observation of the treatment of lupus with +the remedy is so instructive and must be so convincing<span class='pagenum'><a name="Page_c8" id="Page_c8">[c8]</a></span> +as regards the specific nature of the remedy +that every one wishing to occupy himself with the +study of this remedy should if possible make his first +experiments with lupus.</p> + +<p>Less marked, but still apparent to the eye and +touch are the local reactions in tuberculosis of +the lymphatic glands, of the bones and joints, etc., +in which case swelling and increased painfulness, +and in the more superficial parts also a reddening +can be observed.</p> + +<p>The reaction in the inner organs, especially +the lungs is removed from our observation unless we +consider the increased coughing and expectoration +of the patients after the first injection a local reaction. +At the same time we must assume that +these parts undergo changes directly observed in the +case of lupus.</p> + +<p>The different forms of reaction described have +appeared without exception in previous trials on the +dose of .01 ccm. when any form of tuberculosis +prevailed in the system, and therefore I trust that +I am justified in assuming, that in the future this +remedy will constitute an indispensible diagnostic +auxiliary. We will be enabled to diagnose in doubtful +cases of phthisis even then, when it is impossible +to obtain reliable information concerning the nature +of the ailment, by the presence of bacilli or elastic +fibres in the sputum or by a physical examination.<span class='pagenum'><a name="Page_c9" id="Page_c9">[c9]</a></span> +Glandular affectations, hidden tuberculosis of the +bones, doubtful tuberculosis of the skin and the like +will easily and reliably prove to be such. In case of +apparently completed processes of tuberculosis of +the lungs or joints it will be possible to show +whether the process of the disease is in reality a +complete one or establish the existence of centres +from which later on the disease may spread like a +fire from a live coal in the ashes.</p> + +<p>But much more important are the specific qualities +of the remedy than the aids it offers for the +diagnosis.</p> + +<p>While describing the changes, that are caused by +hypodermic injections of the remedy, on the parts +of the skin affected by lupus, attention was called to +the fact that the lupose tissue does not return to its +original condition after the swelling and reddening +have ceased, but is more or less destroyed and disappears. +On some places, as observation teaches, +the process is such, that after a single injection the +diseased tissues undergo mortification and are cast +off as dead matter later on. On other places it +seems that a diminution or rather a kind of melting +of the tissue is caused, and to effect a complete disappearance +a repeated application of the remedy is +necessary. As the required histological investigation +is wanting, it is impossible at the present time +to state with certainty how this result is brought<span class='pagenum'><a name="Page_c10" id="Page_c10">[c10]</a></span> +about. Only this much is known that it is not a +destruction of the tubercle bacilli, but that only the +tissue containing the tubercular bacilli is affected by +the application of the remedy. In this, as the visible +swelling and reddening show, greater circulatory derangements +are caused and with these vital changes +in the <i>assimilation</i> which result in a more or +less rapid and thorough mortification of the +tissue according to the manner in which the remedy +is allowed to act.</p> + +<p>To make a short repetition, the remedy therefore +does not destroy the tubercle bacilli, but the tuberculous +tissue; on dead tissue, for instance, gangrenous +cheesy matter, necrotic bones, etc., it does not act; +nor on tissue that has undergone mortification +through the action of the remedy itself. Living +bacilli can still linger in such dead masses of tissue, +which are either cast out with the necrotic tissue, or +may possibly migrate under special conditions into +the adjoining living tissue.</p> + +<p>This quality of the remedy must be particularly +observed, if its full specific action is to be obtained. +Therefore we must first cause the mortification of +the tuberculous tissue, and then effect its removal as +soon as possible, for instance, by means of a surgical +operation; but where this is impossible and the +excretion by the organisms themselves is necessarily +slow, we must attempt by continued application of<span class='pagenum'><a name="Page_c11" id="Page_c11">[c11]</a></span> +the remedy to protect the endangered living tissue +from the immigration of the parasites.</p> + +<p>As the remedy acts only on living tissue and +causes mortification of tuberculous tissue, we can +readily explain another exceedingly peculiar property +of the remedy, namely, that it can be given in +rapidly increased doses. This may apparently be +explained as being based on inurement. But noting +that in about three weeks the dose may be increased +to 500 times the strength of the first one, it is +unquestionably something more than habit, as we +know of nothing analogous confirming such a rapid +and farreaching adaptation to any powerful drug.</p> + +<p>This fact can rather be explained thus: in the +beginning there is an abundance of living tuberculous +tissue and only a minute quantity of the +effective substance is sufficient to cause a strong +reaction; through each injection a certain quantity +of this responsive tissue disappears, and then relatively +larger doses are required to cause the same +degree of reaction as before. Aside from this adaptation +may assert itself within certain limits. As +soon as the patient is treated with such increased +doses, and that he reacts no more than one not afflicted +with tuberculosis, we may assume that all the +reactive tuberculous tissue is dead. It is then only +necessary to continue the treatment at intervals and +with gradually increased doses as long as any bacilli<span class='pagenum'><a name="Page_c12" id="Page_c12">[c12]</a></span> +remain in the system, to protect the patient from a +new infection.</p> + +<p>It remains to be learnt in the future whether this +conception and the deductions based thereon are +correct. For the present I have directed the manner +of application of the remedy on this basis, which in +our experiments resulted as follows:</p> + +<p>To begin again with the simplest case, namely +lupus, we injected the full dose of .01 ccm. in nearly +all such patients to begin with, and allowed the +reaction to take its full course, after 1–2 weeks we +again injected .01 ccm. and so forth until the reaction +became less and less and finally ceased. In the +case of two patients with facial lupus three respectively +four injections in this manner resulted in a +clean, smooth scar in place of the affected parts; the +remaining patients of this kind have also improved +in a measure proportioned to the time of treatment. +All the patients have suffered from their afflictions +for years and have been treated by various methods +without success.</p> + +<p>Tuberculosis of the glands, bones and joints has +been treated in a very similar manner, as in these +cases larger doses were applied at longer intervals. +The result was the same as with lupus, a rapid cure in +the lighter and milder cases and a slowly progressing +improvement in the severer ones.</p> + +<p><span class='pagenum'><a name="Page_c13" id="Page_c13">[c13]</a></span>With the majority of our patients, those suffering +from pulmonary consumption, the conditions +are somewhat different, patients with decided pulmonary +tuberculosis are very much more responsive +to this remedy, than those afflicted with surgical +tubercles. We were forced to reduce the quantity of +the first dose of .01 ccm. as prepared for the +phthisicist, and we found that as a rule he reacted +strongly on a dose of .002 and even .001 ccm., +but that the quantity could be rapidly increased +from this low initial dose to that which could be +easily tolerated by the other patients. We generally +proceeded in such a manner that the patient at first +received an injection of .001 ccm. and if a rise in the +temperature set in this dose was repeated once daily +until the reaction ceased. Only then the dose was +increased to .002 ccm. and applied till the reactions +failed to appear. And so forth, always increasing +the dose only .001 or at the most .002 up to .01 ccm. +and higher. This mild procedure seemed to me +imperative, especially with such patient as were in a +weak and feeble condition. Proceeding in the +manner just described we can easily attain the application +of very light doses with but slight attacks of +fever and hardly perceptible to the patient. Some of +the stronger consumptives were treated with larger +doses from the beginning, partly with a forced increase +in the dosing when it seemed as though the +favorable result was obtained in a correspondingly<span class='pagenum'><a name="Page_c14" id="Page_c14">[c14]</a></span> +shorter time. The action of the remedy on the +phthisicist generally seemed to be such that cough +and expectoration increased somewhat after the first +injection, then gradually diminished and in favorable +cases disappeared entirely; the sputum lost its +purulent nature and became slimy. The number of +bacilli as a rule did not decrease until the sputum +had attained a phlegmy appearance (only such +patients were selected for these experiments in whose +expectorations bacilli were contained). They entirely +disappeared temporarily, but were again met with +from time to time until the expectoration had completely +stopped. At the same time the night-sweats +left off, and the patients improved in appearance +and gained in weight. All patients treated in the +first stages of phthisis were freed from all symptoms +of disease in the course of 4–6 weeks so that they +could be considered as cured. Even patients with +cavities not too large were considerably improved +and nearly healed. But in the case of such consumptives, +whose lungs contained many and large cavities +no objective improvement could be marked, +although the expectoration diminished and they +appeared to feel much better. I am inclined to +assume on the basis of these experiences, that the +<i>earliest stages of phthisis can with certainty +be cured by this remedy</i>.<a name="FNanchor_3_3" id="FNanchor_3_3"></a><a href="#Footnote_3_3" class="fnanchor">[3]</a> This may also hold +good in cases that are not too far advanced.</p> + +<p><span class='pagenum'><a name="Page_c15" id="Page_c15">[c15]</a></span>In exceptional cases only will pulmonary consumptives, +with large cavities, derive continued +benefits through the application of the remedy, when +other complications exist, for instance, the penetration +of other supurative micro-organisms, irremovable +pathological changes in other organs, etc. Even +such patients were in most cases temporarily improved. +It must follow that even in them the +original process of the disease, tuberculosis, is +influenced in the same manner by this remedy as in +other patients, but that it is impossible to remove +the gangrenous masses of tissue and also the secondary +supurative processes. Naturally we are led to think +that perhaps in some of these severe cases cures may +be effected by means of a combination of this healing +process together with surgical aid (after the manner +of operating empyema) or some other curative +means. I would not advise anyone however, to +apply this remedy without discrimination in every +case of tuberculosis. The simplest mode of application +will certainly be required in treating the first +stages of phthisis and simple surgical affections, but +in all other forms of tuberculosis medical science +should draw on all its resources and individualize +carefully to supplement and sustain the action of the +remedy. In many cases I have had the decided impression +that the attendance to and nursing of the +patient was of no little influence on the curative +process, and therefore I would prefer the application<span class='pagenum'><a name="Page_c16" id="Page_c16">[c16]</a></span> +of the remedy in suitably adapted institutions, where +a close observation of the patient and the adequate +attention to them is possible, to the ambulant or +home treatment. No estimate can at present be +made as to the extent in which a profitable combination +can be made between this new method to cure +and those modes of treatment that have thus far +been considered beneficial, the application of mountain +climate, the free air treatment, specific nourishment, +etc.; but I trust, that these remedial factors +will be of considerable use in conjunction with the +new method in many cases, especially the severe +and neglected as also in the convalescent stages.<a name="FNanchor_4_4" id="FNanchor_4_4"></a><a href="#Footnote_4_4" class="fnanchor">[4]</a></p> + +<p>The nucleus of this new curative method lies in +the earliest possible application. The proper +objects of treatment ought to be the first stages of +phthisis, because here the remedy can fully develop +its curative qualifications. Therefore it is of vital +importance, more so in the future, than it has been +in the past, that practical physicians employ all +possible means to diagnosticate phthisis in as early a +stage as possible. Until lately the finding of tubercle +bacilli existing in the sputum was rather considered +as an interesting incidental evidence, which, although +it insured the diagnosis, was of no further benefit to +the patient and therefore was only too often omitted, +as I have only lately discovered in numerous +cases of phthisis which had passed through the +hands of several physicians without having their<span class='pagenum'><a name="Page_c17" id="Page_c17">[c17]</a></span> +sputum examined once. This must be different in +the future. Any physician who fails to search for +tubercle bacilli in the sputum, to establish phthisis +in as early a stage as possible, commits gross +negligence toward his patient, because his life may +depend on this diagnosis and the specific treatment +which has hurriedly been introduced on this basis. +In doubtful cases the physician should gain certainty +as to the existence or absence of tuberculosis +through a trial injection.</p> + +<p>Only then will the new mode of treatment truly +become a panacea for suffering mankind when that +period is reached, where all cases of tuberculosis are +treated in as early a stage as possible, to prevent +the development of neglected severer cases which +have heretofore formed a continual unlimited source +of new infection.</p> + +<p>In conclusion I would remark, that I have intentionally +omitted all numerical statistics and descriptions +of individual cases in this communication, +because the physicians to whose material the patients +provided for our experiments belonged, have themselves +undertaken the description of their respective +cases and I did not wish to anticipate them in an +objective representation of their observations.</p> + +<div class="footnote"><p><span class='pagenum'><a name="Page_c18" id="Page_c18">[c18]</a></span><a name="Footnote_1_1" id="Footnote_1_1"></a><a href="#FNanchor_1_1"><span class="label">[1]</span></a>Physicians who wish to experiment with the remedy, can +get the same of Dr. A. Libbertz (Berlin, N. W., Lueneburgerstrasse 28 II.), +who has undertaken the production of the +remedy with Dr. Pfuhl's and my assistance. But I must state +that the present stock is very limited, and that larger quantities +can only be disposed of at the end of several weeks.</p></div> + +<div class="footnote"><p><a name="Footnote_2_2" id="Footnote_2_2"></a><a href="#FNanchor_2_2"><span class="label">[2]</span></a>We gave children of 3–5 years of age one tenth of this +dose, that is .001 and very weak children .0005 ccm. and obtained +a strong though not alarming reaction.</p></div> + +<div class="footnote"><p><a name="Footnote_3_3" id="Footnote_3_3"></a><a href="#FNanchor_3_3"><span class="label">[3]</span></a>This statement is necessarily confined in so far as we +have no conclusive experiences, and can not have at present, +that show whether the cure is a permanent one, recidivations +of course are not excluded for the present. But we may +assume that these will be removed as easily and quickly as +the first attack.</p> + +<p>On the other hand it is possible from analogy with other +infectious diseases that those who are once cured become +permanently exempt. This must also be considered an open +question for the present.</p></div> + +<div class="footnote"><p><a name="Footnote_4_4" id="Footnote_4_4"></a><a href="#FNanchor_4_4"><span class="label">[4]</span></a>It was impossible to collect data referring to cerebral-laryngeal- +and miliary-tuberculosis, as we did not have sufficient +material.</p></div> + + + +<p><span class='pagenum'><a name="Page_c19" id="Page_c19">[c19]</a></span></p> +<h2><a name="Explanatory_Notes" id="Explanatory_Notes"></a>Explanatory Notes.</h2> + + +<p>Koch states that he can not at the present make +any statement about the origin and preparation of +the remedy, as his labors are not yet completed.</p> + +<p>We may assume that it is very probably a substance +that corresponds in a way to the lymph used +for vaccination. As vaccine lymph represents variolous +poison greatly reduced in strength, as the +remedy for hydrophobia is composed of a substance +which is weakened hydrophobic poison, so Koch +probably obtains his remedy for tuberculosis by +artificially reducing the tuberculous poison by means +of various processes.</p> + +<p>A number of years ago it has been tried with +syphilis in a similar way to obtain a substance that +would not only cure syphilis but would also guard +against infection from it. At that time however the +experiment was not successful.</p> + +<p>From several intimations I am inclined to believe +that Koch was successful in finding a way in which a +substance may be produced for contagious diseases, +a substance that cures these diseases and also protects +from infection. It is not impossible, since +Jenner found the vaccine virus, Pasteur the hydrophobic +lymph and now Koch the tubercle lymph.</p> + +<p><span class='pagenum'><a name="Page_c20" id="Page_c20">[c20]</a></span>To be sure there is this difference for the present +between the substances named, that the vaccine +virus only protects healthy person from infection by +small pox but it does not cure those sick, while the +hydrophobic lymph and tubercle lymph cure the +afflicted. However Koch seems to believe that his +tubercle lymph has a certain power of producing +immunity.</p> + +<p>According to Koch, his remedy, consisting of a +brownish liquid, is easily perishable as soon as it is +diluted with water; he recommends the preparation +of the dilution of the remedy with a 5 per cent. +phenol solution. Phenol is equivalent to carbolic +acid. The dilution of the remedy for use must be +considerable, as only small quantities of the same +are used.</p> + +<p>Koch tells us that his remedy does not act +through the stomach, that is taken in through the +mouth. On one hand it may be that this is due to +the extremely small quantities necessary for an +effect, on the other hand and principally all the substances +probably act only when they are directly +applied and brought in contact with the circulation +of the blood.</p> + +<p>For a long time small syringes with fine needle +points were used to inject strong acting drugs under +the skin. This is done in a measure to have a +guarantee of a sure effect which is not had by giving<span class='pagenum'><a name="Page_c21" id="Page_c21">[c21]</a></span> +through the mouth. For instance, it is known that +emetics given through the mouth often remain without +results; if however the emetic apomorphine is +injected anywhere under the skin, vomiting surely +follows within a very short time. It is well known +that morphine is injected under the skin in preference +to taking it through the mouth as its action as a +pain killer is much prompter.</p> + +<p>Koch's liquid can also be injected under the skin +with the aid of a so-called Pravaz syringe. Koch +uses a somewhat differently formed syringe. The +result remains the same, no matter what kind of +syringe is used.</p> + +<p>At the same time it makes but little difference, +on what part of the body the injection is made, as +the fluid injected under the skin is distributed at +once over the entire system. Koch chose the skin +of the back between the shoulderblades and the +loins because here the injection could be made without +causing pain or inflammation.</p> + +<p>The production of the liquid must be attended +with great difficulties as Koch plainly remarks that +his stock at present is very limited and he can only +furnish larger quantities at the end of several weeks. +The price of a small bottle to be 25–30 Marks about +6–8 Dollars.</p> + +<p><span class='pagenum'><a name="Page_c22" id="Page_c22">[c22]</a></span>The human being is much more sensitive to +Koch's remedy than the guinea pig, which is commonly +used for experiments of this kind. It seems +that no experiments have as yet been made with +other animals.</p> + +<p>Koch has tried the remedy on himself and has +passed through all the symptoms of a poisoning. +He certainly injected into his arm a considerable +quantity of the liquid; twenty-five times as much as +he injected in his patients.</p> + +<p>But here also there is a difference. In sick +people much smaller quantities act than in the +healthy. One cubic centimeter of the liquid has +hardly any effect on a healthy person, but quite a +marked one on those afflicted with tuberculosis.</p> + +<p>In the case of the latter one cubic centimeter produces +about the same symptoms as twenty-five times +the quantity would in a healthy person. The same +must also be considered as symptoms of poisoning; +but they are only of short duration and are accompanied +with magnificent success.</p> + +<p>Of all diseases based on tuberculosis only ringworm +or lupus is perceivable by the eye, as it is a +disease of the skin, all other tuberculous diseases +take their course in the internal parts of the body, +and therefore are not perceptible to the eye. The +symptoms that follow an injection of Koch's liquid +can be best observed in the case of lupus.</p> + +<p><span class='pagenum'><a name="Page_c23" id="Page_c23">[c23]</a></span>Koch therefore selected for his first illustration +patients afflicted with lupus that is ringworm. Even +a few hours after the injection the first perceptible +changes begin to show in the diseased parts. These +begin to swell and redden; in other words an inflammation +is caused, through which the diseased tissue +is obviously brought to mortification. Soon the inflammation +stops. The gangrenous tissue changes +into crusts or scabs which drop off in a short time +and the patient is cured of his ringworm.</p> + +<p>Koch places particular importance on the fact +that the inflammation is restricted to the diseased +parts only, and that it does not attack sound and +healthy parts. Even the smallest otherwise invisible +knots are made perceptible through the inflammation.</p> + +<p>We have similar illustrations for this specific +action of Koch's remedy for lupus (ringworm). So +for instance a syphilitic ulcer on the thigh may be +cured in a few days with iodide of potassium. In a +similar manner a morbidly enlarged spleen may be +reduced to the normal size by taking quinine.</p> + +<p>The observation is very interesting indeed, as +it may be shown whether a person is tuberculous in +any organ or not by the injection of .01 ccm. In case +he is tuberculous the poisoning symptoms appear in +a marked degree; if he is not, hardly any effect is +noticeable.</p> + +<p><span class='pagenum'><a name="Page_c24" id="Page_c24">[c24]</a></span>Although we have had excellent methods for a +long time to detect pulmonary consumption, although +Koch added the discovery of the tubercle +bacilli, it occasionally happens that the disease can +not be recognized in its beginning stages, because its +progress is too slight. Now the reaction following +an injection is to be the deciding medium. Also with +other tuberculous affections physicians will welcome +this diagnostic auxiliary, for in the beginning of the +same it often happens that no certain diagnosis +could be made and valuable time was lost.</p> + +<p>We must call particular attention to the further +statements of Koch, that through his remedy the +tubercle bacilli are <i>not</i> killed. With this it is admitted +that the remedy will not be able to effect cures, +without any more ado, yes, even the tubercle bacilli +may continue to infect parts of the body even in +spite of the action of the remedy.</p> + +<p>Therefore the application of Koch's remedy only, +is not sufficient to effect a cure. Provision must be +made to remove the gangrenous tissue from the body +as rapidly as possible, because it contains the still +living tubercle bacilli. As a rule surgical aid is necessary +to remove the mortified tissue. Where this +is impossible Koch advises the continued application +of the remedy to protect the endangered living tissue +from the re-immigration of the tubercle bacilli. Koch<span class='pagenum'><a name="Page_c25" id="Page_c25">[c25]</a></span> +thereby believes that he can protect the tissue, +perhaps in the manner as vaccination protects from +small pox.</p> + +<p>The rapid increase in the quantity of the remedy +applied in the course of time is something that has +no parallel. Koch gives an explanation, but leaves +it to the future to be confirmed. We have no previous +instance in case that his explanation should prove +correct. Reasoning from analogous application of our +remedy, we are led to assume that <i>smaller</i> quantities +of the substance would suffice to cause mortification +of the remaining tuberculous tissue. Koch on the +other hand uses larger and larger doses to reach a +result. He admits inurement to the remedy within +certain limits only.</p> + +<p>Koch has made a difference between pulmonary +consumptives and those suffering from tuberculosis +of the bones and joints, etc. He was able to inject +larger quantities in the latter than the former, for +the quantity injected in the case of pulmonary consumptives +was .001 ccm.; in other tuberculous cases +.01 ccm.</p> + +<p>Koch selected pulmonary consumptives for his +experiments, whose sputum contained tubercle bacilli, +so as to make no error in the diagnosis, and to ascertain +by killing the bacilli contained in the sputum, +whether the diseased tend toward restoration. As +the remedy does not kill the bacilli, so a diminution<span class='pagenum'><a name="Page_c26" id="Page_c26">[c26]</a></span> +of the bacilli can only be obtained in that manner, +that the tissue of the lungs undergoes certain changes, +which cause its properties to be such, that the bacilli +are no longer able to exist or propagate in them. +Then a so-called immunity results which we know of +in other similar diseases. We know that anyone +who has had the measles or scarlet fever rarely is +again attacked by the same, as a rule he is permanently +proof against them.</p> + +<p>In the same way as vaccination protects from +small pox, an injection of Koch's remedy acts +against pulmonary consumption. Koch makes a +cautious statement:</p> + +<div class="blockquot"><p>"On the other hand it is possible, from analogy +with other infectious diseases that those who are +once cured become permanently exempt."</p></div> + +<p>Koch reaches this result, that beginning phthisis +can with certainty be cured with his remedy. On the +other hand, advanced consumptives, in whose lungs +large cavities already exist, may possibly be improved +but can not be cured. However he provokes +the idea, that perhaps his method of treatment together +with a surgical operation, that removes all +gangrenous matter from the lungs, may yet have +beneficial results in the end. The idea is not entirely +new to treat lung diseases with the aid of surgery; +unfortunately the operations have heretofore been +thought too risky. Perhaps we will now have a new<span class='pagenum'><a name="Page_c27" id="Page_c27">[c27]</a></span> +branch in operative technic, surgery of the lungs. +Koch advises to conduct this lung surgery after the +manner of operating empyema. This is an operation +performed in the case of suppurative pleurisy to +remove the pus from the pleural cavity. This operation +has been successfully carried out for a long time.</p> + +<p>Koch makes it of especial importance, that +while treating consumption with the new remedy, +the general attendance and nursing is not to be +neglected. Koch also calls attention to what has +been said before, that the general hygienic factors, +good hospital treatment, mountain climate, etc., +will never be dispensed with, on the contrary will be +indispensible to the furtherance of cure.</p> + +<p>In conclusion Koch again remarks that brilliant +results are only promised in the early stages of pulmonary +consumption (phthisis). Physician and +patient must move all levers as to the existence or +non-existence of tuberculous diseases.</p> + +<p>Then those daily pictures of extreme wretchedness +from consumption will be a thing of the past. +Then the danger of contagion will be lessened resulting +from the decrease of the number of tuberculous +persons and of the tubercle-bacilli, and perhaps it +will soon be possible to name the day on which with +the last tubercle-bacillus the ravaging pest, tuberculosis, +will be extirpated.</p> + + + + + + + + +<pre> + + + + + +End of the Project Gutenberg EBook of Prof. Koch's Method to Cure +Tuberculosis Popularly Treated, by Max Birnbaum + +*** END OF THIS PROJECT GUTENBERG EBOOK METHOD TO CURE TUBERCULOSIS *** + +***** This file should be named 27181-h.htm or 27181-h.zip ***** +This and all associated files of various formats will be found in: + https://www.gutenberg.org/2/7/1/8/27181/ + +Produced by Bryan Ness, Norbert H. 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